Specialist guides: patients with different needs

The role of the carer is very important here - see our how-to guide for tips on involving family members or carers

Have a practice run if possible
For video-based consultations we recommend having an informal chat session first – a no pressure chance to become familiar with the technology for the patient and carer. Try to telephone the day before (or on the day of) the video consultation to check that they are prepared and ready.

Choose your platform for video consultations 
If you are able to (check your organisation’s governance requirements), try to select one with a simple user interface, ideally that the patient has used before.

Telerehab and dementia
There is evidence that telerehabilitation can work well for people with dementia, but this depends on having a caregiver as well as an enthusiastic therapist who is familiar with the patient.

“In my experience, telerehabilitation works well with people with mild cognitive impairments. They are more challenging and difficult for people with moderate and severe cognitive impairments - you then rely on the support worker or family.” Occupational Therapist, Neurology

• ‘Your COVID Recovery’ has information on managing the impact of COVID on mind, memory and concentration and the effects on voice, swallowing and communication
• The Stroke Association has useful resources including ‘Getting online for people with aphasia’ and ‘Video calling for people with aphasia’ including guides to Skype, WhatsApp and Zoom

Send out any information beforehand
Advise the parent what will be needed for the consultation to give them time to prepare and so they know how to position the child (e.g. so you can assess joint ranges). Photographs or video guides may be helpful.

Plan the timing of the appointment depending on your goals
Decide whether you want to avoid nap, medication or feeding times or if this will be part of your assessment.

Consider two appointments
One for talking and taking history and another for assessing movement (if this is all done at once it can be a lot for families and children to cope with):

"Complete a triage phone call with a subjective assessment prior to a video call - I find you are then able to target objective assessment or treatment better and are able to prepare the parent or school for what to expect before the call. I find this allows for less stress and better engagement from the child, otherwise the child gets bored and loses interest.” Physiotherapist, Paediatrics

Who should be involved?

If possible involve two adults
If only one parent is present, advise them to use hands-free support or position the device somewhere stable so they are able to engage with the child during the assessment.  

“One adult can position the camera, another can feed back which position is best and model what the child needs to do, or to help position them.” Occupational Therapist, Generic

Consider having two therapists present
One can engage with the parent(s) and child while the other observes.

Other considerations

Observe the child’s normal routine and play
With the parent’s consent, you could take the opportunity at the beginning or end of the consultation, and/or if the child or parent needs a break. This will allow you to see them in their ‘natural’ environment. “You could ask the parents to turn on their camera at the start and just observe before they ask the child to get involved.” Medic, GP and Emergency Medicine

With younger children
Be led by their play, encourage parents to use a portable device such as a smartphone or tablet so that they can follow the child as they move around the room or house. You could use music or ask the parents to involve siblings to keep the child engaged during the appointment.  “You can use a doll to demonstrate on.” Physiotherapist, Paediatrics

Empower the parent to take control
Work with them to decide on specific goals, activities or exercises, and encourage them to work on these in between sessions and feed back on progress.

For a successful video consultation with children
The child needs to be in a good place, not tired or hungry or ill. The parent needs to have time. The therapist needs good communication skills to conduct the session and be able to adapt according to needs of the parent.

Remote consultations with teenagers
There should be negotiation with the teenager and parent about for how much of the session the parent is present. “The aim is for teenagers to self-manage, not be nagged by their parents!” Consultant, Rehabilitation Medicine

• Talk to the patient (and their family member or carer) about what type of consultation they would prefer and feel comfortable with. You might find that a video consultation works better than telephone so that you can see each other and pick up non-verbal cues, but don’t be afraid to suggest a face-to-face appointment if you feel it is necessary.
• Consider two appointments, one for talking, taking history and getting used to the technology, and another for carrying out physical assessments.
• Ask the patient or carer if they have a preferred program for video calls. Try to use this if possible, but remember to check your organisation’s guidance on information governance and security.
• Don’t rush the consultation! Take your time and don’t give too much information at once. If possible, arrange a longer appointment than you would normally.
• The patient might find it harder to focus on a video call than a face-to-face appointment. Be aware of any distractions in their home environment or on their computer screen.
• Speak slowly and clearly. Try to avoid using words or phrases that may be difficult to understand.
• Make the consultation as visual as possible. For example, if you will be assessing movement, show photos, pictures or models over the camera or via screen sharing, and/or demonstrate on yourself or a colleague first.
• Remember that patients with autism may be anxious if the appointment does not start on time or if they have to wait in a virtual waiting room.
• Patients with learning disabilities may rely more on non-verbal communication and cues. See our how-to guide for tips on how to communicate well during a remote consultation.

For further information on communicating with people with a learning disability, see Mencap’s online resources including guidance for healthcare professionals treating COVID-19 patients with learning disabilities.

• If you are sending information or questionnaires in advance of a consultation, try to make sure it is in an accessible format. If this is not possible, take time to read it aloud with the patient.
• Find out whether the patient has accessible technology and if they are familiar with video calling software and accessibility settings. Encourage them to practice using this in advance of the consultation. Partially sighted patients will find a large screen easier to use than a smartphone.
• During the consultation, explain clearly who is present and describe the situation.
• Ask the patient what they are able to see – for example, can they read the names of the practitioners on the screen in a video-based consultation? If they are unable to see this, ensure that each practitioner states their name before speaking. This is particularly important in a group consultation or when several practitioners are present (this is also good practice for consultations in general).
• Try to keep background noise and interruptions to a minimum – rustling papers, tapping the keyboard etc. are distracting and might interfere with communication.
• Remember that patients with sight loss will probably not notice non-verbal communication, particularly on a screen. Clear description is needed instead.
• If you plan to use screen sharing, pay attention to things like contrast, brightness, font size and type. Remember to describe the content carefully as well.
• Try to ensure there is someone with the patient during the consultation, particularly when you are asking them to demonstrate their movement. They can help to set up the technology, help to position the patient in front of the camera and/or provide standby assistance for safety.
• Talk to the patient about what works best for them – remember they are experts in their condition.

• Ask the patient what their preferred method of communication is - what works best for them?
• If patients are hard of hearing but able to lip-read, video may be better than telephone - but quality of the internet connection and camera will be important here. Make sure you are in a well-lit room and not too far from the camera to help with lip-reading. 
• Encourage your patient to use the chat function during a video consultation.
• Involve family members or carers where possible.
• When you are not speaking, mute your microphone to reduce background noise.
• Find out whether the patient has assistive devices or accessible technology (such as the Relay UK app) and make sure they are comfortable with using this prior to the consultation.
  
• Some platforms (e.g. MS Teams, Skype) have an option for audio captions (subtitles), which might be helpful but should be used with caution.
• Make use of e-mail and written resources where possible.

“Advise patients to consider the use of good speakers or headsets if hearing is difficult. It makes a world of difference to the clarity.”
Physiotherapist, Musculoskeletal

For further guidance see the Royal National Institute for Deaf People or the Royal College of General Practitioners’ deafness and hearing loss toolkit

• Use a professional interpreter wherever possible.
• If it is necessary to use a family member as an interpreter, we advise against using children for this purpose.
• Use visual information like pictures, diagrams and demonstration of exercises.
  
• Consider extending the appointment - an assessment with an interpreter can take longer.

“If you are using an interpreter for a three-way video call, let the interpreter know in advance if there are any specific instructions/discussions that you would like the patient to be aware of. It is helpful if the interpreter can contact the person in advance to help them get ready for the consultation. They can provide digital support in a specific language to troubleshoot any issues.”
Equalities and Community Development Support Lead

• You will need to have buy-in from the clinicians and care home staff involved
• Identify one or two digital champions in the care home – people who can help to set up the consultation, assist with technical problems and train other staff
• Speak to a carer who knows the patient well – this should ideally be someone who is involved in their day-to-day care
• Care homes might not know the patient’s detailed medical history – do your homework if you have not seen the patient before!
• Privacy and data protection should be central considerations. The consultation should be done in a private room away from other residents. See our information governance and safety section for more information.
• For care home residents with cognitive impairment or communication difficulties, see our specialist guide (above)

For further information on implementing video consultations in care homes, see the NHSx guide or this guide from Redmoor Health for clinicians and care home staff