This descriptive study identified factors that influenced the receptiveness, use and acceptance of telehealth videophones by 21 family caregivers of stroke patients in the home setting. Potential obstacles to the receptiveness towards videophones included concerns by the caregiver about maintaining home security, limited need for health care support, very low or high degree of burden in caregiving, and discomfort or disinterest in using technology. Identification of possible impediments to the use of videophones is vital prior to developing and evaluating programs using telehealth as a method of rehabilitative technology.
Keywords: collective bargaining, nursing, leadership, ethics, labor
Key words: stroke, caregivers, program evaluation, telehealth, telecommunications, aged, telemedicine, elderly, home care, telecommunications, videophones, caregiver burden
Stroke occurs in about 700,000 people in the United States each year and is one of the leading causes of morbidity in the elderly (Heart disease and stroke statistics, 2004). Patients with stroke go home before they have reached their rehabilitation potential.
Videophones have the advantage of providing services to caregivers who are isolated either due to physical distance...or by disabilities of the patient or caregiver that impede easy travel...
Some researchers have investigated the use of distance technologies to assist caregivers in meeting their needs. For example, telephone interventions have been successfully employed to assist family caregivers in developing problem-solving techniques (Davis, 1998; Grant, Elliott, Giger, & Bartolucci, 2001). Other programs have used web-based support groups and nurse specialists available online to answer questions and provide information for caregivers of stroke survivors (Steiner & Pierce, 2002). One innovative approach that provides support and information to caregivers is the use of telehealth technologies.
The primary goal of this descriptive study was to identify factors that influenced the receptiveness, use, and acceptance of telehealth technologies by caregivers of stroke patients in the home setting.
Strained caregivers may have difficulty in meeting the rehabilitation needs of stroke survivors, putting them at greater risk of ending up in long-term care (Han & Haley, 1999).
...home visits by health professionals are staff intensive, time consuming, and expensive, with limited reimbursement.
Videophones have been used by home care providers to assess patients, monitor their progress, and provide education and support in the home environment.
In several studies, the use of videophones in home care has been found to contribute to the self-management of elderly persons with diabetes, pressure ulcers, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and chronic wounds (Bowles & Dansky, 2002; Finkelstein, Speedie, Lundgren, Demiris, & Ideker, 2001; Rooney, Studenski, & Roman, 1997; Vesmarovich, Walker, Hauber, Temkin, & Burns, 1999). This form of telehealth has been associated with an improvement in the quality of life for patients and productivity for nurses, as well as a reduction of the financial costs associated with mileage and travel (Dimmick, Mustaleski, Burgiss, & Welsh, 2000; Komet, 2001). Videophones have been used by home care providers to assess patients, monitor their progress, and provide education and support in the home environment.
A limited number of studies have been reported on the use of videophones to provide services primarily for the caregivers of family members with chronic illnesses (Buckwalter, Davis, Wakefield, Kienzle, & Murray, 2002; Rivera, Shewchuk, & Elliott, 2003; Wright, Bennet, & Gramling, 1998). Wright and others (1998) studied the use of telehealth visits for caregivers of elderly family members with dementia and a range of physical and mental impairments. Telehealth enabled nurses to offer therapeutic interventions, help caregivers manage behavioral problems caused by dementia, reduce caregiver stress and depression, and mobilize support systems among the family and community. The researchers reported interactive videophones as transforming the relationship between the nurse and caregiver. They stated, "…it [telehealth] ‘declinicalizes’ interactions because caregivers remain in their own home territory; they have a choice of a flexible time schedule; and they determine which problems to address" (p. 79).
Caregiver satisfaction with telehealth has also been studied. In a study in rural Tennessee, telehealth via a standard telephone line was used to provide interventions and support for family caregivers and patients with CHF, COPD, diabetes, cancer, chronic wounds, or receiving parenteral or enteral therapies (Dimmick, Mustaleski, Burgiss, & Welsh, 2000). Family caregivers reported being generally satisfied with the system in that it: (a) saved time by reducing the number of times the patient needed transport to a health center, (b) decreased their anxiety by having health care support readily available, (c) allowed for "just-in-time" health care advice, (d) added value to a telephone report by being able to visualize problems, and (e) increased privacy and convenience.
The objectives of this exploratory descriptive study were to:
- Identify factors that influenced the receptiveness of family caregivers of stroke patients in the home towards a telehealth videophone.
- Describe the utilization patterns and focus of the telehealth calls by the caregivers.
- Compare nurses and caregivers’ acceptance of the "plain old telephone systems" (POTS) based videophone technology.
Human subjects’ approval was obtained from the Institutional Review Board of The Catholic University of America. Participant selection criteria included:
- Male or female at least 40 years of age.
- Primary caregiver of a family member who was a first time stroke survivor in the past six months.
Initial recruitment of potential participants was made via telephone by the chief investigator, a registered nurse. The caregivers were given a brief description of the study and invited to participate. The investigator recorded all comments regarding the caregiver's acceptance or refusal to participate. If verbal agreement was obtained by the caregiver to participate in the study, the caregiver was then assigned to one of four "telehealth nurses," who were registered nurses trained in the use of the videophones. The nurses had a combination of home health and adult medical-surgical experience.
The videophones were practical in price...and allowed for two-way audio and video transmission between the nurses and the caregivers.
Depending upon the availability of equipment, the families received either a desktop or set-top videophone with a black and white or color monitor (8x8 Inc., Santa Clara, CA) (Figure 1). Selection criteria that had been used to select these videophone technologies consisted of being appropriate for the intended use, affordable, readily available, and accessible (Tran, Buckley, & Prandoni, 2002). The videophones were practical in price (approximately $500 per unit) and allowed for two-way audio and video transmission between the nurses and the caregivers over the traditional "plain-old telephone service" or POTS-based system. Although technologies were available on the market that were capable of providing a higher quality of audio and video, their costs were much greater ($1,500 - $10,000 per unit) and would require additional service expenses for higher bandwith telecommunications. (Note: 8x8 Inc. has ceased production of their videophone products, but continue to sell and license their technologies to other POTS videophone vendors).
Figure 1 - Desktop and set-top videophones (8x8 Inc., Santa Clara, CA)
The telehealth nurse scheduled a series of two initial home visits and follow-up weekly telehealth visits with each caregiver over a six-week period. During the initial home visit, the telehealth nurse obtained informed consent from the caregiver and patient, the patient’s medical history and medication profile. The telehealth equipment was installed in the home by a biomedical engineer, who accompanied the telehealth nurse on the first visit. The equipment remained in the home until the completion of the study.
During the initial home visit, the caregivers were screened for their readiness and ability to use the telehealth equipment. They indicated their level of comfort with and interest in using technology in the home (e.g., push button telephones, television remote controls, and computers) as "None", "Minimal", "Moderate" or "A Great Deal." They completed a self-assessment of their visual and auditory acuity and fine motor skills using a 5-point Likert scale ranging from poor to excellent. In addition, the caregivers were asked if they had access to a personal computer in the home.
Within two to three days of the home visit, the nurse made the first telehealth call at the convenience of the caregiver. The primary purpose of the initial call was to check the caregiver’s ability to use the videophone and identify any equipment problems that could be rectified in the follow-up home visit.
Within a week, the telehealth nurse made a second home visit to further assess the patient-caregiver relationship using the Patient-Caregiver Functional Unit Scale (PCFUS). The PCFUS is an interviewer-administered questionnaire in which caregivers evaluate their own physical and emotional difficulties with caregiving and the patients' functional ability (Daly & Fredman, 1998). The reliability and validity of the PCFUS was evaluated in a study of patient-caregiver dyads in three settings: (a) adult caregivers of residents recently admitted to a nursing home (N = 38), (b) caregivers of elderly persons attending a community comprehensive geriatric assessment program (N = 20), and (c) a control group of potential caregivers of elderly adults without serious cognitive or physical problems in an ambulatory medical clinic (N = 85) (Fredman & Daly, 1997). The scale was found to be a valid instrument with an interrater reliability of r = 0.98 and a test-retest reliability of r = 0.89. The telehealth nurse administered the PCFUS to the caregiver to evaluate the patient’s level of dependence in each of seven Activities of Daily Living (ADLs) and seven Instrumental Activities of Daily Living (IADLs), as well as the burden of assisting with each of the ADLs and IADLs. Caregivers who did not assist with a particular ADL or IADL were asked to predict if it would be physically or emotionally difficult to provide assistance. The test took about 10 minutes to administer.
The PCFUS score represents the patient’s level of dependence on a positive scale from 0 (completely dependent) to +28 (completely independent). In contrast, caregiver burden is rated on a negative scale of 0 (no difficulty helping) to –28 (both physically and emotional difficulty helping). The two subscales (patient dependence and caregiver burden) are combined to formulate a total score, which ranges from –28 (the most unstable situation) to +28 (the most stable situation).
For five weeks following the PCFUS assessment, the nurse made weekly telehealth calls to the caregiver. The caregiver was also encouraged to initiate calls. In each telephone interaction the nurse asked a series of open-ended questions on the status of the patient and the caregiver:
- How are things going? Having any problems?
- How is [name of patient] doing (physically, mentally, ADLs)?
- Any difficulties in providing care?
- How are you doing? Any concerns?
The caregiver was encouraged to bring up any issues they deemed important. The nurse kept detailed notes regarding specific content of the interactions. Just before ending the interview, the nurse asked the caregiver if there had been any problems with hearing the audio or viewing the image of the nurse during the call. The nurse completed a similar technical assessment, recording problems with the audio or video, the time and the length of the call, the person (nurse or caregiver) who initiated the call, and the occurrence of any missed or broken connections during the call.
At the end of the six-week period, the telehealth equipment was removed from the home. A registered nurse, who was trained in interviewing techniques, conducted exit interviews of the caregivers and nurses via the telephone. The interviewer obtained the caregivers’ and telehealth nurses’ assessment of the merits and constraints of the technology, as well as the factors that facilitated or hindered the caregivers’ use of the equipment. The caregivers were asked:
- What factors influenced your USING the telehealth equipment?
- What factors influenced your NOT USING the telehealth equipment?
- What were the benefits of having the equipment?
- What were the limitations of having the equipment?
- What would have helped you use the equipment more often?
- How would you rate the ease or difficulty of using the equipment?
The telehealth nurses were asked similar questions, such as:
- What factors contributed to the caregiver’s use of the equipment?
- What factors deterred the caregivers’ use of the equipment?
- What were the benefits of using the equipment?
- What were the limitations of using the equipment?
Data analysis included reading the notes of the videophone interactions and exit interviews, and grouping the content according to recurrent phrases and patterns. The resulting analysis reflected common concerns of the caregivers, and the factors that contributed to or discouraged the use of the telehealth equipment by the caregivers.
Of 75 caregivers who were contacted by telephone and who met the eligibility criteria, only 21 (28%) agreed to participate in the study. The mean age of the sample population was 63.2 ± 10.8 years (Table 1). The majority of these caregivers were African-American, married, female and from a middle-income socioeconomic status. Most of the caregivers had either a high-school diploma or some college education ranging from completion of a two-year program to a Master’s degree, and were full time homemakers.
|Table 1. Demographic Characteristics of Caregivers (N = 21)|
|Age, years |
M ± S.D.
|Gender, n (%) |
|Ethnicity, n (%) |
|Education Level, years |
M ± S.D.
|Relationship, n (%) |
Income Level, n (%)
Employment status, n (%)
Factors Influencing Receptiveness toward Telehealth
Those who elected not to participate in the study cited various reasons, including concerns for personal safety and home security. Caregivers viewed a camera in the home as invasive to their privacy. Elderly caregivers were worried that the camera would provide others with the ability to view information that could allow criminal access to their home. Other reasons given for not participating included not needing health care services and not wanting to learn how to use the equipment. While some caregivers said that they wished they had been offered the opportunity of telehealth when they had first brought their family member home, others were currently so overwhelmed in caring for their family member that learning how to deal with telehealth was an additional burden.
Approximately 95% of the caregivers rated themselves as at least moderately comfortable and moderately interested in technology. The majority also gave themselves good to excellent scores for visual and auditory acuity, as well as for fine motor dexterity. Further, 66% of the subjects had a computer in the home.
Although the results of the PCFUS showed a broad range of scores for the stroke patients' level of dependence upon the caregiver for assistance, they generally reflected a moderate level of dependence (Table 2). The caregivers’ sense of burden also varied widely, but was indicative of a low to moderate level of physical and/or emotional difficulty helping the stroke survivor. The total PCFUS score indicated a borderline level of stability in the caregiving dyad.
|Table 2. - Patient-Caregiver Functional Unit Scale (PCFUS) Scores (N = 21)|
Range in Study
|PCFUS Score |
Mean ± SD
Patient’s Level of Dependence
|0 to +28 |
(most to least dependence)
|+1 to +28||12.7 ± 8.8|
|Caregiver’s Burden||-28 to 0 |
(most to least burden)
|-19 to 0||–7.4 ± 5.6|
|Stability of Patient-Caregiver Dyad||-28 to +28 |
(least to most stable)
|-13 to +26||4.1 ± 11.3|
Utilization Patterns of Telehealth
Seventy-two telehealth visits were attempted by the nurse or caregiver, and 60 (83.3%) of these connections were successfully completed. Some of the reasons for difficulty connecting via telehealth included: (a) time of day, with midday having the greatest incidence of a missed or broken connection, (b) order of visit, with the first and second visits having the highest rate of missed connections, and (c) a change in the equipment set up by the caregiver after being installed. Most (64%) of the telehealth visits were initiated by the nurses.
Caregivers used the videophone to discuss stroke survivors' emotional, cognitive, and behavioral changes, and physical problems...
The content of the telehealth calls by the caregivers was equally divided between discussions focused on the needs of the stroke patients and themselves. Caregivers used the videophone to discuss stroke survivors’ emotional, cognitive, and behavioral changes, and physical problems, such as skin breakdown or incontinence. For example, one female caregiver was concerned about an alteration in her father’s gait. She stated, "His walk is getting worse. I have to worry. He changed his style of walking. Now he walks on his toes. I think he could have had a ministroke." The physician was notified and arrangements were made for a follow-up evaluation.
Several of the female caregivers discussed their concerns with the heavy physical workload, never being able to take a day off, and the mental stress of trying to keep up with their responsibilities and foresee an impending crisis.
Caregivers also talked about their own needs. A common topic of discussion was their physical limitations in caregiving due to chronic health conditions or disability. For example, one woman discussed the impact of her arthritis in trying to provide care for her husband. "My arthritis pain is really terrible. It is difficult to get started doing anything, and I have to do everything for him – feed him, bathe him, wipe his bottom." Caregivers also discussed economic restrictions to getting the support they needed for dealing with the heavy workload of caring for a stroke survivor and a home. Finally, the emotional burden caused by isolation, loneliness, stress, and coping with depression was frequently expressed by caregivers. One elderly woman stated, "I talked to you the last time and it just hit me. I am lonely. There is nobody to talk to. I can’t talk to him, and many of the women friends I had passed away." Several of the female caregivers discussed their concerns with the heavy physical workload, never being able to take a day off, and the mental stress of trying to keep up with their responsibilities and foresee an impending crisis. In many of the sessions, the telehealth nurses used therapeutic communication skills to help caregivers identify their problems and develop goals and a management plan. Referrals for additional counseling and local support groups were also made.
Nurses’ and Caregivers’ Acceptance of POTS-based Videophones
The caregivers and nurses differed in their evaluation of the technical aspects of the POTS-based videophones. Whereas the nurses reported audio and video transmission problems in 40% and 49% of the visits respectively, the caregivers reported problems with the audio for only 14% of the visits, and concerns with the video for 18% of the visits.
Disconnections, voice distortion, loss of sound, poor lighting, and haziness of picture were specific problems reported by the nurses and caregivers. However, it was the nurses who more often described the caregiver as appearing too dark or too light for good visualization. Although portable lighting had been installed while setting up the equipment in the home, the brightness of the day (e.g., sunny, overcast) and whether the client used the installed lighting affected the nurse’s view of the caregiver. In contrast, lighting was better controlled in setting up the telehealth room used by the nurses. Haziness or blurring of the picture would also occur, especially if the client moved excessively during the call. Although the nurses were trained on how to avoid this problem, the clients were not.
A number of caregivers mentioned that telehealth decreased their isolation and stress associated with...the role of the primary caregiver.
In the final interviews with the telehealth nurses and caregivers, both groups reported that they not only accepted the new technology but also were enthusiastic about having an opportunity to use it. The most frequently mentioned benefit of the videophones by both groups was that it offered a convenient method of communication and the exchange of information. A number of caregivers mentioned that telehealth decreased their isolation and stress associated with being at home and assuming the role of the primary caregiver. Almost all of the caregivers described the equipment as being easy to use, and one even declared that she could have "set it up herself."
The most significant limitation that was mentioned by the majority of caregivers concerned the restricted availability of the nurse rather than the technology itself. Many caregivers stated they would have utilized the equipment more often if the nurse had been available for a wider range of hours during the weekdays. Equipment failures and the small size of the picture on some of the telehealth monitors were also mentioned as limitations in using the equipment. Many of caregivers had positive comments about the telehealth nurses who participated in the study. It was evident from the caregivers’ remarks that the nurses played a key role in their overall favorable assessment of the technology and a positive telehealth experience.
In the exit interviews, some telehealth nurses described their level of rapport with the caregiver as having a significant effect on the likelihood of the caregiver initiating calls. The nurses reported developing close therapeutic relationships with some of their clients, who called them more frequently. Other nurses appeared to be making the minimal number of telehealth interactions with few calls initiated by the caregivers. Nurses also reported the initial home visits as key in assessing the patient-caregiver dyad and the home environment, and establishing rapport and trust with the caregivers.
If the caregivers are already feeling overwhelmed by the responsibilities of caregiving, having to learn how to use a new form of technology may be beyond their limits.
Major factors that related to the receptiveness of telehealth were the timing of when it was offered post-discharge and the level of caregiver burden. Caregivers repeatedly expressed the opinion that the option of using telehealth should be introduced at the time of the stroke survivor’s discharge, when they were trying to cope with new needs and responsibilities. The finding that the majority of caregivers who had elected to use the telehealth reported having a moderate level of patient dependence upon them and low to moderate level of burden was consistent with the caregivers’ comments of needing the additional support offered by telehealth and of being moderately comfortable with and interested in technology. This finding suggests that if the level of caregiver burden is low and support systems are in place, the caregivers might not see the need for telehealth. Similarly, a high level of burden could also impede caregivers’ use of telehealth. If the caregivers are already feeling overwhelmed by the responsibilities of caregiving, having to learn how to use a new form of technology may be beyond their limits. As one elderly woman said, "Caring for my husband is all I can handle at this time. I don’t want to get involved in any program. I need a person to help in the home. How can you help me over the phone?"
Offering telehealth technology...when it is most needed and to those who would benefit...is essential to its receptiveness by caregivers.
Offering telehealth technology at a time when it is most needed and to those who would benefit from the additional support is essential to its receptiveness by caregivers. However, for caregivers who are overwhelmed by their responsibilities, helping them find more tangible support is key to meeting their needs. It is possible that caregivers with extreme burden may not recognize their own needs for informational or emotional support or grasp the potential of telehealth in meeting them.
The utilization patterns of the caregivers demonstrated the need for family-centered care when providing services for stroke survivors. Telehealth technology was used by the caregivers to seek informational and emotional support not only for the stroke survivors, but also for themselves. This finding is consistent with the recommendation of Hills (1998), who suggested that:
...health professionals should not automatically assume that the rehabilitation or caregiving roles for the elderly patient are or even should be the main priorities of the caregiver. The family caregiver(s) or potential caregiver(s) of the older individual must be seen from the onset as potential hidden patients needing attention for their own needs, while at the same time being hidden health team members who along with the patient need to be identified as essential health team members. (p. 6)
The caregivers’ needs are closely related to those of the care receiver, and should not be neglected by health professionals if they wish to provide support that prevents or delays institutionalization.
Telehealth technology was used by the caregivers to seek informational and emotional support not only for the stroke survivors, but also for themselves.
It is unclear how much of an impact the perception of the performance of the POTS-based videophones had on its use by the caregivers. Overall, caregivers reported a high level of satisfaction with the technology and the service it provided. They stated the equipment was easy to use and being able to see the nurse through the videophones made the interaction more personal. A few caregivers reported difficulties making or keeping a connection. Since missed connections occurred primarily during the first or second telehealth visits, health care providers and families should anticipate that it may take a couple of calls to become skilled with using the equipment.
Differences in experience and expectation levels between the nurses and caregivers may have also accounted for the disparity in their satisfaction with the performance of the equipment. Each nurse had more experience than the individual caregiver because she was using the equipment with multiple caregivers. Furthermore, the nurses had previous experience with other forms of medical technology, and may have preferred a higher quality image and clearer audio similar to that provided by television. In contrast, many of the caregivers appeared to be satisfied with occasional "choppy" images and were impressed with the novelty of the technology. Home care agencies need to include feedback from patients and caregivers in an evaluation of whatever form of telehealth technology that is selected. It may not be necessary to use the most high-tech equipment that is available. Further, the excessive cost may restrict the number of units available for use with families.
Why some nurses were able to establish more rapport with their clients is not clear. It may that some are more skilled in the therapeutic communication skills required by telehealth (Buckley, Tran, Prandoni, & Clark, 2002; Hughes, 2001). This new mode of communication may require additional training and ongoing evaluation of nurses in therapeutic communication.
Limitations of the study were the small convenience sample that was based on the caregiver’s self-selection and agreement to participate in the study. Thus, there is an inability to generalize the results to other caregivers. Further research is needed to identify whether caregivers at earlier stages in a stroke rehabilitation program and from diverse cultural groups and other community settings (urban, suburban and rural) would have the same or different needs for telehealth connections to health care providers. Additional studies using other forms of telehealth technologies are also required to determine the strengths and limitations of POTS-based technologies from the nurses’ as well as the caregivers’ perspective.
Nurses need to recognize that the hardships and burden of caregiving may rapidly wear down the health of many elderly care providers. Telehealth is one means that allows health professionals the ability to offer services to these families from a distance. Home telehealth can be effective in not only assessing the health care needs of the stroke survivor and caregiver, but also in providing informational and emotional support to them.
Receptiveness toward telehealth appears to be dependent upon: (a) caregivers’ concerns about privacy and home security, (b) proper timing of services offered, (c) perceived need by caregivers for support, and (d) the level of caregiver burden. Methods of assessing caregiver burden, which may be useful in predicting their receptiveness toward telehealth services, are readily available. An assessment of the client’s comfort with and interest in technology as well as auditory and visual limitations may also be important in the acceptance and use of telehealth. The identification of potential blocks to the receptiveness, use and acceptance of telehealth is vital prior to developing, implementing and evaluating programs using it.
The differences in the experience and expectation levels between nurses and caregivers may have led to a disparity with their satisfaction in the performance of the telehealth equipment. Training nurses and caregivers to develop the appropriate communications skills appropriate to the technology and helping them to achieve a minimal level of comfort with telehealth is essential to its use and effectiveness. Further studies are needed to determine if acceptance, use and satisfaction of telehealth by caregivers changes over time with additional experience.
Kathleen M. Buckley, PhD, RN
Kathleen M. Buckley, PhD, RN is an Associate Professor in the School of Nursing at The Catholic University of America, where she teaches in the undergraduate nursing program. She also practices clinically as a home health nurse for Adventist Home Health, Silver Spring, MD. She served as the Principal Investigator on a telehealth project with the Rehabilitation Engineering Research Center on Telerehabilitation, which used advanced telecommunications systems for remote delivery of nursing support for caregivers of stroke survivors.
Binh Q. Tran, PhD
Binh Q. Tran, PhD is an Associate Professor of Biomedical Engineering at The Catholic University of America. He is the Director of the HomeCare & Telerehabilitation Technology Center and the Academic Director of the Rehabilitation Engineering Research Center on Telerehabilitation. The Center, founded in 1999, participates in research, design, evaluation, and training efforts in the fields of home health care and telehealth technologies. Dr. Tran’s major research and academic interests are cardiac and pulmonary mechanics, biomedical instrumentation, and telehealth and home health care technologies.
Cheryl M. Prandoni, MSN, RN
Cheryl M. Prandoni, MSN, RN is the Director of Learning Resources and Adjunct Assistant Professor in the School of Nursing at The Catholic University of America. Ms. Prandoni has worked extensively with an older population in clinical practice and teaches undergraduate nursing students. Working on the telehealth project enabled her to introduce nursing students to this technology and relate it to clinical practice.
Article published August 31, 2004
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The authors would like to acknowledge the support of the National Institute on Disabilities and Rehabilitation of the U.S. Dept. of Education under Grant # H133E980025. All expenses, including the telehealth equipment, nurses’ salaries, supplies, etc. were fully funded by the granting agency with no compensation from private insurance or Medicare. The opinions herein are those of the grantees and not necessarily of the granting institution.
We wish to thank the telehealth nurses, Barbara Beyna, Annette Debisette, Mary Fran Kenny and Stephanie Holaday, for their assistance in carrying out this work, and the caregivers and their families for their participation.