Socioculturally Appropriate Internet-Based Geriatric Care Model for Older Adults Living With HIV: Experience-Based Co-Design Approach

We have read the paper by Cheryl Modica et al on Advancing Virtual at-Home Care for Community Health Center Patients Using Patient Self-Care Tools, Technology, and Education. 1 We congratulate all authors who provide interesting information regarding health services that use virtual models that integrate self-care tools and technologies. This is interesting because since the beginning of the COVID-19 pandemic, health centers have switched to a virtual service delivery model. Providing efficient, coordinated and high-quality services is important for the prevention and management of chronic disease conditions in patients. Virtual health services that use self-care tools and technology are an important model for increasing access to care for hard-to-reach patients. 2 The study conducted by Cheryl Modica et al aimed to explore the use of virtual care models, implemented using a systems approach and patient-driven tools and technologies, on clinical measurement performance and patient experience. 1 However, there are several obstacles that have arisen that can be caused by virtual care, including communities whose connectivity and access to technology is still limited and also concerns about primary health services, where there is a focus on relational continuity of services based on relationships between patients and health workers due to the widespread use of virtual services. 3 Therefore we must pay attention to several things before using a virtual care model including (1) the guiding principles needed for measuring virtual care; (2) best practices implemented to measure the quality of virtual services aligned with face-to-face frameworks; (3) Increasing the implementation of virtual services which have an impact on patient access and experience as well as the scale of measurement; (4) constraints and barriers faced by organizations in developing a quality virtual service framework; and (5) Application of virtual services in various patient cases. 4 The results of Cheryl Modica et al's study showed a statistically significant improvement in patients who completed the initial 4 virtual visits and reported decreased depression and increased satisfaction with virtual care visits compared to inperson visits. 1 However, healthcare professionals also need to evaluate the use of virtual visit platforms in primary care, examine patient and physician preferences for virtual communication methods, and report on visit characteristics and patient experience of care. Although there are concerns that virtual visits will be overused by patients, many virtual visits appear to be replacing in-person visits. This approach can improve access and continuity of primary health services. 5 In conclusion we agree that primary healthcare services that implement virtual care models with patient self-care tools, technology, and education, experience improvements in chronic condition prevention and patient recovery. 1 However, it is important to review how the use of virtual health services has evolved and ensure patients have access to the platform for a longer period of time. Therefore, further research is needed which must also focus on the use of administrative data to track the impact of virtual services on the use of face-to-face primary health services, emergency department visits and hospitalizations, as well as exploring how the use of virtual care impacts. 5

Alternate "hospital avoidance" models of care are required to manage the increasing demand for acute inpatient beds. There is currently a knowledge gap regarding the perspectives of hospital clinicians on barriers and facilitators to a transition to virtual care for low back pain. We plan to implement a virtual hospital model of care called "Back@Home" and use qualitative interviews with stakeholders to develop and refine the model. We aim to explore clinicians' perspectives on a virtual hospital model of care for back pain (Back@Home) and identify barriers to and enablers of successful implementation of this model of care. We conducted semistructured interviews with 19 purposively sampled clinicians involved in the delivery of acute back pain care at 3 metropolitan hospitals. Interview data were analyzed using the Theoretical Domains Framework. A total of 10 Theoretical Domains Framework domains were identified as important in understanding barriers and enablers to implementing virtual hospital care for musculoskeletal back pain. Key barriers to virtual hospital care included patient access to videoconferencing and reliable internet, language barriers, and difficulty building rapport. Barriers to avoiding admission included patient expectations, social isolation, comorbidities, and medicolegal concerns. Conversely, enablers of implementing a virtual hospital model of care included increased health care resource efficiency, clinician familiarity with telehealth, as well as a perceived reduction in overmedicalization and infection risk. The successful implementation of Back@Home relies on key stakeholder buy-in. Addressing barriers to implementation and building on enablers is crucial to clinicians' adoption of this model of care. Based on clinicians' input, the Back@Home model of care will incorporate the loan of internet-enabled devices, health care interpreters, and written resources translated into community languages to facilitate more equitable access to care for marginalized groups.

Virtual hybrid hotel care model for the surgical patient: New goal of global academic surgery to improve global outcomes

Health centers are community-based, patient directed primary care providers that offer accessible, high-quality primary care within medically underserved communities. Screening for cancer and managing complex chronic conditions such as diabetes, hypertension, obesity, and depression are vital services for the vulnerable populations seen by community health centers. Delivering care for complex chronic conditions and preventive services using virtual models that integrate self-care tools and technology is an important approach to increasing access for hard-to-reach patients served by health centers. This study aimed to explore the use of a virtual care model, applied using a systems approach and patient-driven tools and technology, on the performance of clinical and patient experience measures. A virtual care model, applied using a systems approach offered by the Value Transformation Framework (VTF), was combined with self-care tools and technology in twenty health centers across 17 states to drive improvement efforts. Changes in clinical measures and patient experience were compared. A total of 385 patients were enrolled and 270 (70.1%) completed a baseline visit and at least four virtual visits during the six-month intervention period. Statistically significant improvements were seen in measures for HbA1c, systolic and diastolic blood pressure, and bodyweight. Among the 270 who completed the baseline and at least 4 virtual visits, the percentage up-to-date for colorectal cancer screening increased from 113/270 (41.9%) to 169/270 (62.6%) after six months, p<0.001, a 20.7% increase. Patients completing the baseline visit and at least 4 virtual visits reported a 10.7% decrease in depression and increased satisfaction with virtual care visits compared to in-person visits (p<0.001). Health centers applying the Value Transformation Framework's organizing framework to the use of virtual care models together with patient self-care tools, technology, and education, had improvements in measures for chronic and preventive conditions and patient experience.

ABSTRACTBackgroundVirtual care is increasingly being used to deliver outpatient cancer services, yet people from culturally and linguistically diverse (CALD) backgrounds can experience inequities in accessing these services. A range of complex and context‐specific factors impact the effectiveness of virtual care and equity in its use and outcomes. This study draws on the methodological principles of realist evaluation to provide contextual understanding and account of how, why and in what circumstances outpatient virtual care services work (or not) for people from CALD backgrounds accessing cancer services in Australia.DesignRealist evaluation, a theory‐driven approach, allows researchers to provide a nuanced understanding of how, for whom and why different interventions work (or not) under different circumstances. We propose an iterative and stakeholder‐driven four‐phase study design that is exploratory and sequential, following the Realist and Meta‐narrative Evidence Synthesis: Evolving Standards (RAMESES II) quality standards for realist studies. Phase 1 will generate the initial program theory from a realist synthesis of theories for how virtual care interventions are implemented into routine care and semi‐structured interviews with key stakeholders, including CALD service providers, service leaders and people with cancer and/or their carers who are from CALD backgrounds. Phase 2 will use semi‐structured realist interviews and focus group discussions with stakeholders and retroductive, theory‐driven realist analysis to test and refine the initial program theory. Phase 3 will validate the program theory with a small purposive participant sample outside those who participated in phases 1 and 2. The final phase will coproduce theory‐informed actionable recommendations and guidelines for effective virtual models of care implementation through interactive workshops with consumers, managers, service leaders and providers.DiscussionKnowledge of the contexts and mechanisms that produce optimal outcomes from virtual care is essential to guide the design, adjustment and implementation of virtual care models that provide equitable care outcomes for all patients. Outputs from this realist evaluation, including the program theory and actionable recommendations and guidelines, will inform policy and practice about implementing or adjusting virtual care models and policies or procedures in Australian healthcare to make them more accessible and equitable.Patient or Public ContributionThe conceptualisation and design of this study were developed with healthcare consumers from diverse cultural and linguistic backgrounds, healthcare providers and academics as part of a national project in Australia. Multicultural consumers who have lived experience of accessing cancer services contributed to the project's design as investigators and are coauthors of this protocol paper. Patients and the public are also represented as Project Steering Group members who will inform the data collection processes, development, and refinement of our program theory.

BackgroundWidespread adoption of digital tools and technologies now support the delivery of virtual healthcare. Although, consumer engagement is central to care processes in virtual care models, there is paucity of evidence regarding the nature and outcomes of consumer engagement. This study aimed to determine the nature of consumer engagement used in virtual models of care, and its impact on quality and safety of care. MethodsA systematic review was undertaken with a narrative synthesis, with a search strategy applied to five electronic databases (CINAHL, EMBASE, MEDLINE, PsycINFO and Web of Science) ResultsFifty-eight studies were included in the review that utilised a variety of virtual models of care across care services. Consumer engagement, such as patients’ active involvement in monitoring, capturing and reporting their health data, was a common feature of the identified virtual models. ConclusionIncreasing use of virtual models of care requires consideration of the role of patients and their support persons in the use of technology and in wider care processes that occur at a distance from health professionals. Ensuring consumers are equipped with necessary support to effectively engage in virtual care is important to ensure equity in access to, and outcomes of, virtual care models.

Background: Due to the COVID-19 pandemic, many community palliative healthcare providers shifted from providing care in a patient’s home to providing almost exclusively virtual palliative care, or a combination of in-person and virtual care. Research on virtual palliative care is thus needed to provide evidence-based recommendations aiming to enhance the delivery of palliative care during and beyond the pandemic. Aim: To explore the experiences and perceptions of community palliative care providers, patients and caregivers who delivered or received virtual palliative care as a component of home-based palliative care during the COVID-19 pandemic. Design: Qualitative study using phone and video-based semi-structured interviews. Data were analyzed using thematic analysis. Setting/participants: A total of 37 participants, including community palliative care patients/caregivers (n = 19) and healthcare providers (n = 18) recruited from sites in Ottawa and Toronto, Ontario, Canada. Results: Overall, participants preferred in-person palliative care compared to virtual care, but suggested virtual care could be a useful supplement to in-person care. The findings are presented in three main themes: (1) Impact of COVID-19 pandemic on community palliative care services; (2) Factors influencing transition from exclusively virtual model of care back to a blended model of care; and (3) Recommended uses and implementation of virtual palliative care Conclusions: Incorporating virtual palliative care into healthcare provider practice models (blended care models) may be the ideal model of care and standard practice moving forward beyond the COVID-19 pandemic, which has important implications toward organization and delivery of community palliative care services and funding of healthcare providers.

AP-453071-2 SYNCHRONOUS AND ASYNCHRONOUS ATRIAL FIBRILLATION EDUCATION DIRECTED BY ALLIED PROFESSIONALS FOR IMPROVED PATIENT CARE

BackgroundA broad-based international shift to virtual care models over recent years has accelerated following COVID-19. Although there are increasing numbers of studies and reviews, less is known about clinicians’ and consumers’ perspectives concerning virtual modes in contrast to inpatient modes of delivery.MethodsWe conducted a mixed-methods study in late 2021 examining consumers’ and providers’ expectations of and perspectives on virtual care in the context of a new facility planned for the north-western suburbs of Sydney, Australia. Data were collected via a series of workshops, and a demographic survey. Recorded qualitative text data were analysed thematically, and surveys were analysed using SPSS v22.ResultsAcross 12 workshops, 33 consumers and 49 providers from varied backgrounds, ethnicities, language groups, age ranges and professions participated. Four advantages, strengths or benefits of virtual care reported were: patient factors and wellbeing, accessibility, better care and health outcomes, and additional health system benefits, while four disadvantages, weaknesses or risks of virtual care were: patient factors and wellbeing, accessibility, resources and infrastructure, and quality and safety of care.ConclusionsVirtual care was widely supported but the model is not suitable for all patients. Health and digital literacy and appropriate patient selection were key success criteria, as was patient choice. Key concerns included technology failures or limitations and that virtual models may be no more efficient than inpatient care models. Considering consumer and provider views and expectations prior to introducing virtual models of care may facilitate greater acceptance and uptake.

Introduction Despite its reported benefits, the accelerated adoption of virtual care since the COVID-19 pandemic has occurred without critical consideration of clinician education and training. This integrative review aims to better understand the necessary education guidelines, frameworks and resources for building the confidence and capability of the workforce for virtual care delivery. Methods Whittemore and Knafl's (2005) five-stage methodological framework informed this review. Using a clearly articulated search strategy and reporting process, over 8000 pieces of literature were analysed. A final 46 publications comprising 26 scholarly papers and 20 pieces of grey literature were included for review. Results A set of key curriculum inclusions under three domains: clinical, administrative and technical are proposed. Many publications emphasise a domain-specific approach as the most effective means of translating virtual care knowledge and skills to practice. A number of new domain frameworks have been tailormade for specific disciplines, while well-established frameworks such as the ACGME, CanMEDS, AAMC and IPEC have been adapted for virtual care education. Virtual care checklists, clinical champions and models that involve frontline clinicians, content experts and care recipients are considered useful resources for virtual care education. Discussion Moving beyond the COVID-19 pandemic, virtual care education for current and future clinicians requires a cohesive, interprofessional approach. This approach should be rigorously evaluated as part of a continuous quality improvement process.

All learning objectives were met. This rotation was particularly effective at allowing residents to hone history-taking, communication, counselling, and rapport-building skills due the nature of providing care virtually. In the absence of the ability to examine patients or use body language to support interactions, residents learned to ascertain patients’ emotions and build common-ground without the benefit of face-to-face interaction. The rotation provided increased exposure to the wide scope of ambulatory internal medicine, sparking at least one resident’s interest in ambulatory care. The rotation initially focused on COVID-19 care to allow residents to feel part of the solution to the pandemic. During the PAR reflection process, we identified that residents felt that CPAC care was algorithmic and less educational than GIM clinics. To improve the educational experience of the AVCR, we now provide opportunities in virtual subspecialty medicine clinics. For technical reasons, video visits only became a possibility partway through the rotation; and we will be incorporating more for the next iteration. Barriers to implementing virtual care, privacy, legal issues, and payment models were suggested as topics of formal discussion during the rotation; we will be incorporating these topics into a weekly journal club. Administratively, finding supervisors for residents was challenging. Faculty cited having to learn the novel technology and keep abreast with the ever-evolving COVID-19 knowledge required to supervise as deterrents. Clarifying supervisory expectations for attending physicians can be helpful; nonetheless, getting buy-in from sufficient potential supervisors was only achieved through significant persistence. Notably, the flow of resident supervision in clinical interactions was not different. Patients accepted waiting on hold for case review. Moreover, speakerphone and video telecommunication made engaging in conversations between the attending physician, residents, and patients seamless. AVCR was a success. The demand for virtual care is increasing, as is the need to educate physicians in these newer models of care.2 Incorporating novel models of care into residency should be done irrespective of a pandemic in order to build residents’ skills for the future and to integrate such ‘novel’ models of care into everyday medicine.

Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated. To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital. High-risk adult hospital discharge patients in Toronto were randomly assigned to either the virtual ward or usual care. A total of 1923 patients were randomized during the course of the study: 960 to the usual care group and 963 to the virtual ward group. The first patient was enrolled on June 29, 2010, and follow-up was completed on June 2, 2014. Patients assigned to the virtual ward received care coordination plus direct care provision (via a combination of telephone, home visits, or clinic visits) from an interprofessional team for several weeks after hospital discharge. The interprofessional team met daily at a central site to design and implement individualized management plans. Patients assigned to usual care typically received a typed, structured discharge summary, prescription for new medications if indicated, counseling from the resident physician, arrangements for home care as needed, and recommendations, appointments, or both for follow-up care with physicians as indicated. The primary outcome was a composite of hospital readmission or death within 30 days of discharge. Secondary outcomes included nursing home admission and emergency department visits, each of the components of the primary outcome at 30 days, as well as each of the outcomes (including the composite primary outcome) at 90 days, 6 months, and 1 year. There were no statistically significant between-group differences in the primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. The primary outcome occurred in 203 of 959 (21.2%) of the virtual ward patients and 235 of 956 (24.6%) of the usual care patients (absolute difference, 3.4%; 95% CI, -0.3% to 7.2%; P = .09). There were no statistically significant interactions to indicate that the virtual ward model of care was more or less effective in any of the prespecified subgroups. In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge. clinicaltrials.gov Identifier: NCT01108172.

Regulatory and professional nursing associations have an important role in ensuring that nurses provide safe, competent, and ethical care and are capable of adapting to emerging phenomena that influence society and population health needs. Telehealth and more recently virtual care are 2 digital health modalities that have gained momentum during the COVID-19 pandemic. Telehealth refers to telecommunications and digital communication technologies used to deliver health care, support health care provider and patient education, and facilitate self-care. Virtual care facilitates the delivery of health care services via any remote communication between patients and health care providers and among health care providers, either synchronously or asynchronously, through information and communication technologies. Despite nurses' adaptability to delivering virtual care, many have also reported challenges. This study aims to describe resources about virtual care, digital health, and nursing informatics (ie, practice guidelines and fact sheets) available to Canadian nurses through their regulatory and professional associations. An environmental scan was conducted between March and July 2023. The websites of nursing regulatory bodies across 13 Canadian provinces and territories and relevant nursing and a few nonnursing professional associations were searched. Data were extracted from the websites of these organizations to map out educational materials, training opportunities, and guidelines made available for nurses to learn and adapt to the ongoing digitalization of the health care system. Information from each source was summarized and analyzed using an inductive content analysis approach to identify categories and themes. The Virtual Health Competency Framework was applied to support the analysis process. Seven themes were identified: (1) types of resources available about virtual care, (2) terminologies used in virtual care resources, (3) currency of virtual care resources identified, (4) requirements for providing virtual care between provinces, (5) resources through professional nursing associations and other relevant organizations, (6) regulatory guidance versus competency in virtual care, and (7) resources about digital health and nursing informatics. Results also revealed that practice guidance for delivering telehealth existed before the COVID-19 pandemic, but it was further expanded during the pandemic. Differences were noted across available resources with respect to terms used (eg, telenursing, telehealth, or virtual care), types of documents (eg, guideline vs fact sheet), and the depth of information shared. Only 2 associations provided comprehensive telenursing practice guidelines. Resources relative to digital health and nursing informatics exist, but variations between provinces were also noted. The use of telehealth and virtual care services is becoming mainstream in Canadian health care. Despite variations across jurisdictions, the existing nursing practice guidance resources for delivering telehealth and virtual care are substantial and can serve as a beginning step for developing a standardized set of practice requirements or competencies to inform nursing practice and the education of future nurses.

BackgroundWhile virtual care services existed prior to the emergence of COVID-19, the pandemic catalyzed a rapid transition from in-person to virtual care service delivery across the Canadian health care system. Virtual care includes synchronous or asynchronous delivery of health care services through video visits, telephone visits, or secure messaging. Patient advisors are people with patient and caregiving experiences who collaborate within the health care system to share insights and experiences in order to improve health care.ObjectiveThis study aimed to understand patient advisors’ perceptions related to virtual care and potential impacts on health care quality.MethodsWe adopted a phenomenological approach, whereby we interviewed 20 participants who were patient advisors across Canada using a semistructured interview protocol. The protocol was developed by content experts and medical education researchers. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Data collection stopped once thematic saturation was reached. The study was conducted at Queen’s University, Kingston, Ontario. We recruited 20 participants from 5 Canadian provinces (17 female participants and 3 male participants).ResultsSix themes were identified: (1) characteristics of effective health care, (2) experiences with virtual care, (3) modality preferences, (4) involvement of others, (5) risks associated with virtual care encounters, and (6) vulnerable populations. Participants reported that high-quality health care included building relationships and treating patients holistically. In general, participants described positive experiences with virtual care during the pandemic, including greater efficiency, increased accessibility, and that virtual care was less stressful and more patient centered. Participants comparing virtual care with in-person care reported that time, scheduling, and content of interactions were similar across modalities. However, participants also shared the perception that certain modalities were more appropriate for specific clinical encounters (eg, prescription renewals and follow-up appointments). Perspectives related to the involvement of family members and medical trainees were positive. Potential risks included miscommunication, privacy concerns, and inaccurate patient assessments. All participants agreed that stakeholders should be proactive in applying strategies to support vulnerable patients. Participants also recommended education for patients and providers to improve virtual care delivery.ConclusionsParticipant-reported experiences of virtual care encounters were relatively positive. Future work could focus on delivering training and resources for providers and patients. While initial experiences are positive, there is a need for ongoing stakeholder engagement and evaluation to improve patient and caregiver experiences with virtual care.

In an increasingly complex health care environment, the prompt recognition of critical illnesses, such as cardiogenic shock, is imperative for improving patient outcomes. Telehealth services, such as the integration of virtual intensive care units, can facilitate collaboration between clinicians to expedite treatment of complex conditions. In this case report, an intensive care nurse practitioner's use of telehealth resulted in prompt diagnosis and treatment for a patient with cardiogenic shock. The patient was initially treated for presumed septic shock. The intensive care nurse practitioner suspected cardiogenic shock and consulted with an intensivist using a virtual intensive care model of care. The patient was treated for cardiogenic shock and has returned to his baseline status, despite the morbidity and mortality typically associated with cardiogenic shock. Integration of virtual intensive care units in other health systems can offer one way to improve outcomes for critically ill patients, especially those with low-frequency, high-risk conditions.