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Service Delivery Innovation Profile

At-Home, Internet-Enabled Therapy Sessions Enhance Access to Cognitive Rehabilitation for Traumatic Brain Injury Patients, Leading to High Levels of Patient and Therapist Satisfaction

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The Mayo Clinic provides remote cognitive rehabilitation sessions to patients who have had an acquired brain injury. Using an Internet-based, secure instant-messaging platform, an office-based therapist conducts the rehabilitation session with the patient, who remains in or near his or her home. Patients experience improved functioning, and both patients and therapists report high levels of satisfaction with the program, which has enhanced access to rehabilitation services for patients who otherwise would find it difficult to travel to clinic facilities.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized, controlled trial, pilot-test results, and a post-implementation evaluation of patient outcome and satisfaction.
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Developing Organizations

Mayo Clinic
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Use By Other Organizations

Although many other centers are conducting telerehabilitation, very few studies such as this one have been conducted to determine the effectiveness of telerehabilitation.begin pp

Patient Population

Vulnerable Populations > Rural populationsend pp

Problem Addressed

Patients with an acquired brain injury often require cognitive therapy to regain memory and other cognitive deficits lost from the injury, but many patients find it difficult to travel to such sessions and thus miss out on this valuable service.1
  • A common problem, especially in rural areas: Each year, 1.7 million people experience a traumatic brain injury (TBI) in the United States. The leading causes of TBI are falls, motor vehicle crashes, hits to the head, and assaults.2 Rural states tend to have higher TBI fatalities and disabilities than more urban states and areas.3
  • Difficulty accessing rehabilitation services: In some areas, particularly rural ones, many patients have limited access to health care due to the long travel distances required and inclement weather that may occur many months of the year. The Mayo Clinic, for example, cares for patients from all over the United States, so patients often have to travel hours to be seen in person. Frequent bad weather conditions often lead to missed appointments. In addition, patients with TBI often face other cognitive difficulties that make lengthy travel to appointments difficult, if not impossible.1
  • Remote therapy a viable option: The use of remote therapy has the potential to reach more patients in rural and distant areas. Remote therapy can also eliminate the need for TBI patients to find transportation, navigate parking, and engage in other travel-related activities they may find challenging.

What They Did

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Description of the Innovative Activity

The program involves in-office therapists using an instant-messaging platform to communicate and conduct cognitive therapy sessions with patients who remain in or near their homes. Key elements of the program are described below:
  • Patient recruitment: Eligible patients have a moderate-to-severe acquired brain injury, are between the ages of 18 and 65, and have access to a computer, either in their home or at a local library. Patients are recruited through announcements in Mayo's Traumatic Brain Injury newsletter, meetings, and support groups. Moderate-to-severe TBI is defined as patients with a Glasgow Coma Scale score below 13, posttraumatic amnesia lasting more than 24 hours, neurological imaging evidence of trauma-related abnormalities, memory impairment on standardized cognitive testing, complaints of memory impairment, and complaints of reduction in social activity and daily functioning.
  • Remote therapy sessions: Using the instant messaging-platform, sessions are conducted between the therapist and patient, who participate without family or outside assistance. During the sessions, the therapist and subject work through a memory notebook training program, a commonly used tool that has been a successful part of therapy in the Mayo Clinic for more than 20 years. A memory notebook is an example of an aid used to help TBI patients cope with memory loss by compensating for lost memory ability. This training program uses an evidence-based treatment approach, including stages of acquisition, application, and adoption of strategies designed to help patients manage memory problems. To duplicate the ability to "see" facial expressions and other patient emotions (as would occur in face-to-face encounters), "smiley faces," font color, and font size are used to demonstrate enthusiasm and other emotions the patient may be experiencing.

Context of the Innovation

Mayo Clinic is a nonprofit, integrated group medical practice that has more than 3,300 physicians, scientists, and researchers who work on all types of medical specialties. More than 46,000 allied health staff at the clinic treat more than a half-million people annually in sites in Minnesota, Florida, and Arizona. Mayo Clinic has been designated by the National Institute of Disability and Rehabilitation Research as 1 of 16 Traumatic Brain Injury Model Systems in the country (see As a Traumatic Brain Injury Model Systems-designated organization, Mayo has built on these findings and is currently involved in the study of long-term recovery after TBI and the development of innovative services to address the needs of patients with TBI through better coordination of health services and reintegration into their local communities.

Did It Work?

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A post-therapy assessment found very high levels of patient and therapist satisfaction with the program:
  • Patient satisfaction was high: A majority of patients reported being satisfied or very satisfied with the therapy. Few, if any, patients reported distress related to the therapy. All participants believed that the therapist genuinely cared about them. Almost all of the subjects would use the instant-messaging platform for therapy again.4
  • Therapist satisfaction was high, driven by increased productivity: Participating therapists strongly supported the program, which enabled them to see more patients with fewer cancellations.
  • Even patients with severe memory impairment were able to use the program: In an initial efficacy study, only 2 out of 10 participants missed any therapy sessions after 1 to 2 hours of training on the instant-messaging system, for a total miss rate of 4 percent.5
  • Patients improved functioning after completion of study: An initial study found that, after completion of 60 online sessions with a therapist, individuals displayed significant increases in use of compensation strategies (e.g., calendar use) and were rated by their families as having improved in memory and mood.6 In a second study using a randomized, controlled trial design, researchers found that after 30 treatment sessions, persons receiving active treatment experienced a significant increase in level of independence compared with a waiting list control group.7

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized, controlled trial, pilot-test results, and a post-implementation evaluation of patient outcome and satisfaction.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Recruiting and training therapists: Therapists in this study were drawn from the brain rehabilitation team at Mayo. Therapists used the same therapy approach that they use in their day-to-day clinical practice but did so in accordance with the research protocol. The therapists also received brief training on use of the instant-messaging system; no additional training was required because the therapy session fell within the scope of their traditional duties.
  • Developing the system: Mayo Clinic worked with a division of Google to create a secure, simple instant-messaging system that allows patients to click on the icon at their home computer, enter a name and password, and instantly begin chatting with their therapist and engaging in therapy. The system uses tight security features to protect privileged communications.
  • Training patients: Participating patients received training from Mayo Clinic staff on the instant-messaging platform; training typically lasted less than 2 hours but was not considered complete until participants showed that they could use the system on their own. The purpose of the training was to ensure a smooth transition into therapy at a remote location.

Resources Used and Skills Needed

  • Staffing: One therapist led the sessions at first, with a second therapist added later. Other Mayo Clinic staff assisted with program logistics and patient training. A total of 31 patients participated in the project.
  • Costs: The costs for the program were low. The time involved in system development was donated by Google. When the project was done in 2008, the rate for this instant-messaging system was $15/month for unlimited use. Most participants already had a computer or access to one, so there was no need to purchase computer equipment. Other costs included reimbursement for travel expenses for patients to come to Mayo for assessment and initial training on how to use the instant-messaging system.
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Funding Sources

National Institute on Disability and Rehabilitation Research; Google
Current research was funded through June 2011 by a grant from the Mayo Foundation Center for Translational Science Activities. Earlier studies were funded by a grant from the National Institute on Disability and Rehabilitation Research. Google donated the majority of the time and resources required to develop the secure instant-messaging system.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Seek outside funding for the program: The primary costs relate to building security into the system, something that Google largely donated to Mayo.
  • If delivery therapy, review state licensing requirements: This project was done as a research study, but if it is done to deliver actual therapy, licensing requirements for therapists who participate in the program need to be reviewed to ensure compliance with state requirements. Because each state has different licensing regulations and laws, therapists who lead sessions remotely may have to be licensed in each state where their patients reside.
  • Work with third-party payers and national advocacy groups: Groups such as the American Telemedicine Association may be able to provide reimbursement and billing procedures for the services.

Sustaining This Innovation

  • Periodically educate staff about the benefits of the program: Sharing information on high levels of patient satisfaction can be helpful in securing their support, which is critical to sustaining the program.

Use By Other Organizations

Although many other centers are conducting telerehabilitation, very few studies such as this one have been conducted to determine the effectiveness of telerehabilitation.

Additional Considerations

  • People with memory impairment and moderate-to-severe TBI are able to reliably and independently use the Internet for therapy sessions. Based on the positive response of initial program participants, Mayo expanded the program to include people with other types of brain injuries.
  • In the current study, the program has expanded beyond TBI to include all persons with moderate-to-severe acquired brain injury.

More Information

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Contact the Innovator

Thomas Bergquist, PhD, LP, ABPP
Principal Investigator
Mayo Clinic
(507) 255-4058

Innovator Disclosures

Dr. Bergquist reported having no financial interests or business or professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

References/Related Articles

Forducey PG, Glueckauf RL, Bergquist TF, et al. Telehealth for persons with severe functional disabilities and their caregivers: facilitating self-care management in the home setting. Psychol Serv. 2012;9(2):144-62. [PubMed] (Added December 2012.)

Mayo Clinic. Traumatic brain injury model system. Available at:

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Traumatic brain injury. Available at:


1 Johnstone B, Price T, Bounds T, et al. Rural/urban differences in vocational outcomes
for state vocational rehabilitation clients with TBI. NeuroRehabilitation. 2003;18(3):197-203. [PubMed]
2 Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths, 2002-2006. 2010. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)
3 Gabella B, Hoffman RE, Marine WW, et al. Urban and rural traumatic brain injuries in Colorado. Ann Epidemiol. 1997;7(3):207-12. [PubMed]
4 Bergquist TF, Thompson K, Gehl C, et al. Satisfaction ratings after receiving Internet-based cognitive rehabilitation in persons with memory impairments after severe acquired brain injury. Telemed JE Health. 2010;16(4):417-23. [PubMed]
5 Bergquist T, Gehl C, Lepore S, et al. Internet-based cognitive rehabilitation in individuals with acquired brain injury: a pilot feasibility study. Brain Inj. 2008;22(11):891-7. [PubMed]
6 Bergquist T, Gehl C, Mandrekar J, et al. The effect of Internet-based cognitive rehabilitation in persons with memory impairments after severe traumatic brain injury. Brain Inj. 2009;23(10):790-9. [PubMed]
7 Forducey PG, Glueckauf R, Bergquist TF, et al. Telehealth for persons with severe functional disabilities and their caregivers: facilitating self-care management in the home setting. Psychol Serv. 2012;9(2):144-62. [PubMed]
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Original publication: August 04, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 19, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.