Assistive technology for independence and safe discharge
Prescription and supply of assistive technology, including the use of home visits
Research shows that assistive technology is important for supporting independence, as is an occupational therapy evaluation to prescribe the technology. However, a home visit has not been found to be as important.
A wide range of assistive technology is available, including:
- Simple or low-risk assistive technology, which is relatively inexpensive and can be independently purchased from stores or online.
- Complex assistive technology, equipment which can be expensive and requires individualised fitting and instruction.
Funding schemes will influence the ability of health professionals to prescribe interim versus definitive recommendations, as well as opportunities for the stroke survivor themselves to determine their own needs. In addition, the health organisation needs to be considered, as does the state of COVID-19 restrictions; some processes within standard care may be able to be changed to accommodate alternative ways of working, but some will not.
Together, these considerations will influence joint decision-making about the type of assistive technology prescribed (i.e., equipment vs home modification), permanence (interim vs definitive), and timing (to enable discharge vs to support long-term independence).
|Complexity level||Evidence summary||Resources & tips|
Simple or low-risk assistive technology
NDIS classifies these as Basic (Level 1) and Standard (Level 2).
It includes grab-rails or handrails, walking sticks, pick-up frames, wheeled walkers, eating equipment, bath boards or transfer benches, shower chairs and stools, toilet seat raises or frames that go over the toilet.
Together, research suggests that consumers and their families are likely able to identify their own equipment needs in this category, but should be assisted by relevant health professionals to support decision-making based on pre-morbid ADL and IADL functioning, current ADL functioning and areas of concern and confidence gaps.
An understanding of the person-environment fit remains important. It can be obtained through a structured occupational therapy interview relating to functional ability and available community supports, alongside photographs of the home environment with measurements provided by the family or neighbours if needed. Studies have used standardised forms and/or instruction booklets to support families to take photographs and measurements suitable for modifications (Clemson et al. 2016). Challenging areas for accurate measurement across studies seem to include door jambs, stair risers, bed height, bath lip widths, and toilet circulation space. Advising how to measure these spaces would seem worthwhile.
All pre-discharge home assessment studies included education and in-hospital trials of prescribed equipment, as well as modified methods of completing ADL and IADL tasks using the equipment; some included written advice in addition to verbal advice. Post-discharge home visit trials were compared to “usual care” or no intervention.
Simple or low-risk assistive technology can often be self-prescribed by the adult with stroke (without the support of a health professional). The UNSW DIYModify app provides information for making changes to a home for comfort, safety and easier living.
The home modification items included are: handheld showers; grab rails; handrails; threshold ramps and level shower access. This app provides free, Australian information to step people through the choices available, how to install, how to maintain and clean the items, and what to do if the home is not owned or is under Strata Title.
Where support from a health professional is required, have family take photos of environment and take measurements. Provide instructions on how to measure. Handy tip: include the tape measure in the photo.
Specialised assistive technology
NDIS classifies these as Specialised (Level 3). This assistive technology is generally adjusted to suit the individual support needs.
Examples include power or power-assist wheelchairs, pressure mattresses, mobile hoists, bath lifts, simple or non-structural home modifications.
These items are used as they are supplied (without adaptation) but it is important to make sure the assistive technology is setup correctly.
There is limited RCT evidence to guide practice in prescribing specialised assistive technology. Health professionals would routinely support decision-making in the prescription of this equipment, and to fit the equipment or ensure safe use of a new, non-structural home modification.
An understanding of the person-environment fit remains important. It can be obtained through a structured in-hospital interview about functional ability and available community supports, alongside photographs of the home environment with measurements provided by the family or neighbours.
To fit or check that the assistive technology is set up correctly, consideration could be given to the use of video-conferencing where face-to-face therapist review is not possible. Research in this area is limited, however the end-user familiarity with videoconferencing appears key, and the limited research completed may suggest that photographs, emails and telephone calls have greater acceptance with some clients.
|The HACE tool administered by an OT allows in- hospital assessment of the home and community environments.
The IMPACT2 model presented by Steel & Layton (2016) in their AT prescription study provides guidance on factors to consider when evaluating the fit and set-up.
Complex assistive technology
NDIS classifies these as Complex (Level 4). They may be custom-made, or off-the-shelf but adjusted to suit individual support needs and requiring linking with other assistive technology supports.
Examples include environmental control units, sleep systems, communication devices, complex home modifications (such as bathroom modifications, e.g. removing the bath).
There is limited RCT evidence to guide practice in the prescription of complex assistive technology. Health professionals would routinely support decision-making in prescribing this equipment, trial options or customise the equipment (e.g. seating systems), and then fit the equipment or ensure safe use of a new home modification.
It may not be possible to prescribe complex assistive technology while meeting your health professional requirements without being face-to-face with the client, and as such we suggest that only interim prescriptions for complex assistive technologies be made if a face-to-face assessment of the person and the fit and modifications of the assistive technology are not possible. For example, instead of a definitive prescription of a ramp, a temporary ramp (which is a low-risk assistive technology device) may be more appropriate in the short term.
Evidence on the effectiveness of home visits
In writing this, we acknowledge a long-held belief that pre-discharge home visits, in particular those undertaken by occupational therapists, improve discharge transitions from hospital to home (with outcomes cited including safety, readmission prevention, improved ADL performance, falls prevention). While an occupational therapy assessment is recommended in the Clinical Guidelines, whether it needs to involve a visit to the home has not been well established.
To support joint decision-making, we highlight the following research that has successfully prescribed assistive technology to support functional ability and community support. Where applicable, we highlight whether the study population included adults with stroke.
None of the included studies were conducted during COVID-19
- Fukumoto M, et al (2019). Home visits by occupational therapists in acute hospital care: a systematic review. Int J Rehabil Res. 2019 Sep;42(3):205-210. doi: 10.1097/MRR.0000000000000350.
Systematic review concluded that there is no adequate evidence to support routine home visits by an occupational therapist at the time of transition from hospital to home.
- Clemson L, et al. (2016). Occupational therapy predischarge home visits in acute hospital care: a randomized trial. J Am Geriatr Soc. 64(10):2019-2026. doi: 10.1111/jgs.14287
Study found no additional benefit of a pre-discharge and post-discharge home visit in comparison to receiving a structured OT interview with in-hospital equipment trial plus education. Study used the HACE tool for the in-hospital assessment to understand a person’s home and community environment, and included a subset of participants with stroke.
- Drummond A, et al (2013). Occupational therapy predischarge home visits for patients with a stroke (HOVIS): results of a feasibility randomized controlled trial. Clin Rehabil. 27(5):387-97. doi: 10.1177/0269215512462145
Study included n=93 adults with stroke, and found no difference on any outcome between those patients who received a pre-discharge OT Home visit, and those who received an in-hospital structured OT assessment (standardised tool not published).
- Wong FK, et al. (2008). Can home visits help reduce hospital readmissions? Randomized controlled trial. J Adv Nurs.62(5):585-95. doi: 10.1111/j.1365-2648.2008.04631.x.
Study of post-discharge (<30days) home visits from nurses did improve satisfaction with care, but no other outcomes (not ADL, readmission rates, safe use of equipment)
Evidence of the effectiveness of remote assistive technology prescription
We acknowledge there are videoconference home visit studies that have been completed; however, none were randomised controlled trials and the majority used non-specialist tech assistants or other health professionals to videoconference from within the home environment.
In light of the lack of RCT evidence supporting the effectiveness of the home visit, this list focuses specifically on the prescription of assistive technology rather than conducting home visits.
- Cudd, P. et al (2017) Observing remote prescription of AT. Studies in Health Technology and Informatics, 242. pp. 94-97. ISSN 0926-9630
This paper published 4 case studies in UK where health professionals used videoconferencing supported remote AT prescription. The AT end users were school children, the AT experts were based in a hospital. Noted that the health professionals used a variety of videoconferencing methods, and that the health professionals reverted to using photographs and recorded videos, as well as face-to-face appointments when the client’s use of technology was challenged.
- Lemaire ED (2001). Low-bandwidth, Internet-based videoconferencing for physical rehabilitation consultations. J Telemed Telecare. 2001;7(2):82-9.
This paper describes the use of videoconferencing to provide physical rehabilitation consultation services (they used videoconferencing and file transmission using a PC and modem, and a separate telephone line for voice). Interventions included wheelchair prescription and authors report that all clients were comfortable with and had confidence in the teleconsultations.
- Schein R.M., et al. (2008). Development of a service delivery protocol used for remote wheelchair consultation via telerehabilitation. Telemedicine and e-Health.Nov 2008.932-938.
Schein R.M., et al. (2010) Patient Satisfaction with Telerehabilitation Assessments for Wheeled Mobility and Seating, Assistive Technology, 22:4, 215-222, DOI: 10.1080/10400435.2010.518579
These papers describe a rural clinic approach to wheelchair prescription using videoconferencing alongside anthropometric measurement and supported by experienced wheelchair prescribing therapists in an urban area. While all clients were satisfied with their tele-consults, these did have a local support person available during the consultation.
This general advice is synthesised from published evidence and is not specific to an individual client
Professor Natasha Lannin
Department of Neuroscience, Monash University
Alfred Health (Allied Health)
Dr Kylie Wales
Lecturer, Occupational Therapy, University of Newcastle