Patient, caregiver and other knowledge user engagement in consensus-building healthcare initiatives: a scoping review protocol.

INTRODUCTION: Patient engagement and integrated knowledge translation (iKT) processes improve health outcomes and care experiences through meaningful partnerships in consensus-building initiatives and research. Consensus-building is essential for engaging a diverse group of experienced knowledge users in co-developing and supporting a solution where none readily exists or is less optimal. Patients and caregivers provide invaluable insights for building consensus in decision-making around healthcare, policy and research. However, despite emerging evidence, patient engagement remains sparse within consensus-building initiatives. Specifically, our research has identified a lack of opportunity for youth living with chronic health conditions and their caregivers to participate in developing consensus on indicators/benchmarks for transition into adult care. To bridge this gap and inform our consensus-building approach with youth/caregivers, this scoping review will synthesise the extent of the literature on patient and other knowledge user engagement in consensus-building healthcare initiatives. METHODS AND ANALYSIS: Following the scoping review methodology from Joanna Briggs Institute, published literature will be searched in MEDLINE, EMBASE, CINAHL and PsycINFO databases from inception to July 2023. Grey literature will be hand-searched. Two independent reviewers will determine the eligibility of articles in a two-stage process, with disagreements resolved by a third reviewer. Included studies must be consensus-building studies within the healthcare context that involve patient engagement strategies. Data from eligible studies will be extracted and charted on a standardised form. Abstracted data will be analysed quantitatively and descriptively, according to specific consensus methodologies, and patient engagement models and/or strategies. ETHICS AND DISSEMINATION: Ethics approval is not required for this scoping review protocol. The review process and findings will be shared with and informed by relevant knowledge users. Dissemination of findings will also include peer-reviewed publications and conference presentations. The results will offer new insights for supporting patient engagement in consensus-building healthcare initiatives. PROTOCOL REGISTRATION: https://osf.io/beqjr.

Quality measures of virtual care in ambulatory healthcare environments: a scoping review.

OBJECTIVES: Delivery of virtual care increased throughout the COVID-19 pandemic and persisted after physical distancing measures ended. However, little is known about how to measure the quality of virtual care, as current measures focus on in-person care and may not apply to a virtual context. This scoping review aims to understand the connections between virtual care modalities used with ambulatory patient populations and quality measures across the Quintuple Aim (provider experience, patient experience, per capita cost, population health and health equity). DESIGN: Virtual care was considered any interaction between patients and/or their circle of care occurring remotely using any form of information technology. Five databases (MEDLINE, Embase, PsycInfo, Cochrane Library, JBI) and grey literature sources (11 websites, 3 search engines) were searched from 2015 to June 2021 and again in August 2022 for publications that analysed virtual care in ambulatory settings. Indicators were extracted, double-coded into the Quintuple Aim framework; patient and provider experience indicators were further categorised based on the National Academy of Medicine quality framework (safety, effectiveness, patient-centredness, timeliness, efficiency and equity). Sustainability was added to capture the potential for continued use of virtual care. RESULTS: 13 504 citations were double-screened resulting in 631 full-text articles, 66 of which were included. Common modalities included video or audio visits (n=43), remote monitoring (n=11) and mobile applications (n=11). The most common quality indicators were related to patient experience (n=58 articles), followed by provider experience (n=25 articles), population health outcomes (n=23 articles) and health system costs (n=19 articles). CONCLUSIONS: The connections between virtual care modalities and quality domains identified here can inform clinicians, administrators and other decision-makers how to monitor the quality of virtual care and provide insights into gaps in current quality measures. The next steps include the development of a balanced scorecard of virtual care quality indicators for ambulatory settings to inform quality improvement.

An assessment of adaptation and fidelity in the implementation of an audit and feedback-based intervention to improve transition to adult type 1 diabetes care in Ontario, Canada.

BACKGROUND: The fit between an intervention and its local context may affect its implementation and effectiveness. Researchers have stated that both fidelity (the degree to which an intervention is delivered, enacted, and received as intended) and adaptation to the local context are necessary for high-quality implementation. This study describes the implementation of an audit and feedback (AF)-based intervention to improve transition to type 1 diabetes adult care, at five sites, in terms of adaptation and fidelity. METHODS: An audit and feedback (AF)-based intervention for healthcare teams to improve transition to adult care for patients with type 1 diabetes was studied at five pediatric sites. The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) was used to document the adaptations made during the study. Fidelity was determined on three different levels: delivery, enactment, and receipt. RESULTS: Fidelity of delivery, receipt, and enactment were preserved during the implementation of the intervention. Of the five sites, three changed their chosen quality improvement initiative, however, within the parameters of the study protocol; therefore, fidelity was preserved while still enabling participants to adapt accordingly. CONCLUSIONS: We describe implementing a multi-center AF-based intervention across five sites in Ontario to improve the transition from pediatric to adult diabetes care for youth with type 1 diabetes. This intervention adopted a balanced approach considering both adaptation and fidelity to foster a community of practice to facilitate implementing quality improvement initiatives for improving transition to adult diabetes care. This approach may be adapted for improving transition care for youth with other chronic conditions and to other complex AF-based interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT03781973. Registered 13 December 2018. Date of enrolment of the first participant to the trial: June 1, 2019.

Supporting and Incentivizing Peer Leaders for an Internet-Based Private Peer Community for Youths With Type 1 Diabetes: Social Network and Directed Content Analysis.

BACKGROUND: Youths with type 1 diabetes (T1D) frequently experience stigma. Internet-based peer communities can mitigate this through social support but require leaders to catalyze exchange. Whether nurturing potential leaders translates into a central role has not been well studied. Another issue understudied in such communities is lurking, the viewing of exchanges without commenting or posting. OBJECTIVE: We aimed to assess the centrality of the peer leaders we selected, trained, and incentivized within the Canadian Virtual Peer Network (VPN)-T1D. This is a private Facebook (Meta Platforms, Inc) group that we created for persons aged 14 to 24 years with T1D. We specifically sought to (1) compare a quantitative estimate of network centrality between peer leaders and regular members, (2) assess the proportions of network exchanges that were social support oriented, and (3) assess proportions of high engagement (posts, comments, reactions, and votes) and low engagement (lurking) exchanges. METHODS: We recruited peer leaders and members with T1D from prior study cohorts and clinics. We trained 10 leaders, provided them with a monthly stipend, and encouraged them to post on the private Facebook group we launched on June 21, 2017. We extracted all communications (posts, messages, reactions, polls, votes, and views) that occurred until March 20, 2020. We calculated each member's centrality (80% of higher engagement communications comprising posts, comments, and reactions plus 20% of members with whom they connected). We divided each member's centrality by the highest centrality to compute the relative centrality, and compared the mean values between leaders and members (linear regression). We calculated the proportions of communications that were posts, comments, reactions, and views without reaction. We performed content analysis with a social support framework (informational, emotional, esteem-related, network, and tangible support), applying a maximum of 3 codes per communication. RESULTS: VPN-T1D gained 212 regular members and 10 peer leaders over 33 months; of these 222 members, 26 (11.7%) exited. Peer leaders had 10-fold higher relative centrality than regular members (mean 0.53, SD 0.26 vs mean 0.04, SD 0.05; 0.49 difference; 95% CI 0.44-0.53). Overall, 91.4% (203/222) of the members connected at least once through posts, comments, or reactions. Among the 75,051 communications, there were 5109 (6.81%) posts, comments, and polls, 6233 (8.31%) reactions, and 63,709 (84.9%) views (lurking). Moreover, 54.9% (3430/6253) of codes applied were social support related, 66.4% (2277/3430) of which were informational (eg, insurance and travel preparation), and 20.4% (699/3430) of which were esteem related (eg, relieving blame). CONCLUSIONS: Designating, training, and incentivizing peer leaders may stimulate content exchange and creation. Social support was a key VPN-T1D deliverable. Although lurking accounted for a high proportion of the overall activity, even those demonstrating this type of passive participation likely derived benefits, given that the network exit rate was low. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/18714.

A virtual mother-infant postpartum psychotherapy group for mothers with a history of adverse childhood experiences: open-label feasibility study.

OBJECTIVES: Mothers with a history of adverse childhood experiences (ACE) are at elevated risk for postpartum mental illness and impairment in the mother-infant relationship. Interventions attending to maternal-infant interactions may improve outcomes for these parents and their children, but barriers to accessing in-person postpartum care limit uptake. We adapted a postpartum psychotherapy group for mothers with mental illness (e.g., mood, anxiety, trauma-related disorders) and ACE for live video-based delivery, and evaluated feasibility, acceptability, and preliminary efficacy in an open-label pilot study. METHODS: We recruited adults with children (6-18 months) from a perinatal psychiatry program in Toronto, Canada. The intervention was a live video-based 12-week interactive psychotherapy group focused on maternal symptoms and maternal-infant relationships. The primary outcome was feasibility, including feasibility of recruitment and retention, fidelity of the intervention, and acceptability to patients and group providers. Maternal clinical outcomes were compared pre- to post-intervention, as secondary outcomes. RESULTS: We recruited 31 participants (mean age 36.5 years (SD 3.9)) into 6 groups; 93.6% (n = 29) completed post-group questionnaires, and n = 20 completed an optional post-group acceptability interview. Mean weekly group attendance was 83% (IQR 80-87); one participant (3.2%) dropped out. All group components were implemented as planned, except for dyadic exercises where facilitator observation of dyads was replaced with unobserved mother-infant exercises followed by in-group reflection. Participant acceptability was high (100% indicated the virtual group was easy to access, beneficial, and reduced barriers to care). Mean maternal depressive [Edinburgh Postnatal Depression Scale: 14.6 (SD 4.2) vs. 11.8 (SD 4.2), paired t, p = 0.005] and post-traumatic stress [Posttraumatic Stress Disorder Checklist for DSM-5: 35.5 (SD 19.0) vs. 27.1 (SD 16.7)], paired t, p = 0.01] symptoms were significantly lower post vs. pre-group. No differences were observed on mean measures of anxiety, emotion regulation or parenting stress. CONCLUSIONS: Recruitment and retention met a priori feasibility criteria. There were significant pre- to post-group reductions in maternal depressive and post-traumatic symptoms, supporting proceeding to larger-scale implementation and evaluation of the intervention, with adaptation of dyadic exercises.

A Multimodal Intervention for Reducing Unnecessary Repeat Glycated Hemoglobin Testing.

OBJECTIVES: Reducing unnecessary tests that do not enhance quality can promote health-care value. Glycated hemoglobin (A1C) is often ordered at a frequency exceeding the recommendation of once every 3 months. We conducted a quality improvement (QI) initiative aimed to reduce unnecessary repeat testing by 75% at a tertiary care academic hospital. METHODS: A retrospective baseline analysis was conducted on laboratory data from 2019 that enumerated unnecessary A1C tests, defined as repeat tests ordered within 60 days. A multifaceted change intervention with iterative plan-do-study-act cycles was introduced in March 2019 to educate providers and to automatically cancel A1C tests requested within 60 days. Monthly totals of A1C testing processed were plotted on statistical process control charts. RESULTS: In 2019, 11% of all A1C tests ordered were unnecessary. Between March 2020 and January 2021, 11% of the tests (N=14,247 tests) were unnecessary, of which 84% were cancelled with our intervention. Providers in cardiology and nephrology accounted for over half (55%) of the unnecessary tests ordered. CONCLUSIONS: A 2-pronged approach informed by root-cause analysis, and comprised of gatekeeping and provider education, can effectively promote resource stewardship for reducing unnecessary A1C testing.

Pandemic Preparedness and Beyond: Person-Centred Care for Older Adults Living in Long-Term Care during the COVID-19 Pandemic.

The increasing complexity of residents' needs, emphasis on social distancing and limited access to high-quality support presented challenges to patient-centred care during the pandemic. Yet the pandemic created an opportunity to explore novel approaches to achieving person-centred care within long-term care (LTC). We share three projects designed to enhance care delivery in the context of the pandemic: to address personhood needs during outbreaks, to improve the quality of medical care and to deliver personalized palliative and end-of-life care using a prediction algorithm. These projects enabled better care during the pandemic and will continue to advance person-centred care beyond the pandemic.

Patient and Provider Experiences With Virtual Care in a Large, Ambulatory Care Hospital in Ontario, Canada During the COVID-19 Pandemic: Observational Study.

BACKGROUND: Virtual care use increased during the COVID-19 pandemic. The impact of that shift on patient and provider experiences is unclear. OBJECTIVE: We evaluated patient and provider experiences with virtual visits across an academic, ambulatory hospital in Toronto, Canada and assessed predictors of positive experience with virtual care. METHODS: Survey data were analyzed from consenting patients who attended at least one virtual visit (video or telephone) and from consenting providers who delivered at least one virtual visit. Distributions for demographic variables and responses to survey questions are reported, with statistical significance assessed using chi-square tests and t tests. Ordinal logistic regression analysis was used to identify any patient predictors of responses. RESULTS: During the study period, 253 patients (mean age 45.1, SD 15.6 years) completed 517 video visit surveys, and 147 patients (mean age 41.6, SD 16.4 years) completed 209 telephone visit surveys. A total of 75 and 94 providers completed the survey in June 2020 and June 2021, respectively. On a scale from 1 to 10 regarding likelihood to recommend virtual care to others, fewer providers rated a score of 8 or above compared with patients (providers: 62/94, 66% for video and 49/94, 52% for telephone; patients: 415/517, 80% for video and 150/209, 72% for telephone). Patients of non-White ethnicity had lower odds of rating a high score of 9 or 10 compared with White patients (odds ratio 0.52, 95% CI 0.28-0.99). CONCLUSIONS: Patient experiences with virtual care were generally positive, but provider experiences were less so. Findings suggest potential differences in patient experience by ethnicity, warranting further investigation into equity concerns with virtual care.

Gaps in Referral to Bariatric Surgery for Patients With Type 2 Diabetes Seen in Endocrinology Clinics.

OBJECTIVES: One-third of adults in Canada are overweight and 26.8% experience obesity. Bariatric surgery confers effective weight loss and reduces obesity-related complications, including type 2 diabetes, but remains an underutilized treatment. Our objective in this study was to determine whether a gap exists in bariatric program referrals for patients with type 2 diabetes seen in endocrinology clinics at an ambulatory tertiary care hospital in Toronto, Canada. METHODS: A retrospective chart review was conducted of 843 consecutive patients with type 2 diabetes in endocrinology clinics between January 1, 2015 and December 31, 2020. Inclusion criteria were age ≥18 years, type 2 diabetes and body mass index (BMI)>35 kg/m2. Exclusion criteria were recent active cancer, uncontrolled psychiatric disease or active substance use disorder within 6 months of the initial visit. Referrals to bariatric surgery were assessed within a 5-year follow-up period and compared with baseline referral rates from the Ontario Bariatric Network (OBN). An online survey of 48 endocrinologists in Toronto, Ontario, was also conducted to assess physician-level barriers to referral. RESULTS: The proportion of patients with class II obesity (BMI>35 kg/m2) and type 2 diabetes meeting the eligibility criteria for bariatric referral was 4.6% (n=38). A documented discussion about bariatric surgery occurred with 7 (18.0%) of these eligible patients, and 1 patient (2.6%) was referred for surgery. Aside from surgical referrals, only 2.6% of eligible patients were referred to cognitive-behavioural therapy, 36.8% were initiated on obesity pharmacotherapy and 42.1% were referred to a dietitian. Baseline OBN data demonstrated that most surgical referrals (n=6,360) were from family physicians (65.0%) and only 8.8% were from a medical specialist. Eight percent of surveyed endocrinologists reported that they discussed bariatric surgery with at least half of their eligible patients. The most frequent barrier to discussing bariatric surgery during visits was time constraints. Physicians identified that simplifying the referral process and providing bariatric surgery handouts would be helpful interventions to improve referral rates. CONCLUSIONS: Our gap analysis demonstrated a low bariatric surgery referral rate by tertiary care endocrinologists. Our study also identified a large gap in the appropriate treatment of obesity with poor utilization of behavioural, lifestyle and pharmacotherapy practices. As obesity and diabetes rates increase, better education, training and knowledge translation will be necessary to overcome weight bias and prioritize obesity management.

Patient-reported outcome measures for assessing health-related quality of life in people with type 2 diabetes: A systematic review.

Patient-Reported Outcome Measures (PROMs) are important tools to assess outcomes relevant to patients, with Health-Related Quality Of Life (HRQOL) as an important construct to be measured. Many different HRQOL PROMs are used in the type 2 diabetes field, however a complete overview of these PROMs is currently lacking. We therefore aimed to systematically describe and classify the content of all PROMs that have specifically been developed or validated to measure (aspects of) HRQOL in people with type 2 diabetes. A literature search was performed in PubMed and EMBASE until 31 December 2021. Studies on the development or validation of a PROM measuring HRQOL, or aspects of HRQOL, in people with type 2 diabetes were included. Title and abstract and full-text screening were conducted by two independent researchers and data extraction was performed independently by one of the researchers. Data were extracted on language in which the PROM was developed, target population, construct(s) being measured, names of (sub)scales and number of items per (sub)scale. In addition, all PROMs and subscales were classified according to specific aspects of HRQOL based on the Wilson & Cleary model (symptom status, functional status, general health perceptions) to aid researchers in PROM selection. In total 220 studies were identified that developed or validated PROMs that measure (aspects of) HRQOL in people with type 2 diabetes. Of the 116 unique HRQOL PROMs, 91 (of the subscales) measured symptom status, 60 measured functional status and 26 measured general health perceptions. In addition, 16 of the PROMs (subscales) measured global quality of life. 61 of the 116 PROMs (subscales) also include characteristics of the individual (e.g. aspects of personality, coping) or environment (e.g. social or financial support) and patient-reported experience measures (PREMs, e.g. measure of a patient's perception of their personal experience of the healthcare they have received, e.g. treatment satisfaction), which are not part of the HRQOL construct. Only 9 of the 116 PROMs measure all aspects of HRQOL based on the Wilson & Cleary model. Finally, 8 of the 116 PROMs stating to measure HRQOL, measured no HRQOL construct. In conclusion, a large number of PROMs are available for people with type 2 diabetes, which intend to measure (aspects of) HRQOL. These PROMs measure a large variety of (sub)constructs, which are not all HRQOL constructs, with a small amount of PROMs not measuring HRQOL at all. There is a need for consensus on which aspects of HRQOL should be measured in people with type 2 diabetes and which PROMs to use in research and daily practice. PROSPERO: CRD42017071012. COMET database: http://www.comet-initiative.org/studies/details/956 .

Quality of virtual care for ambulatory care sensitive conditions: Patient and provider experiences.

BACKGROUND: The COVID-19 pandemic and the need for physical distancing has led to rapid uptake of virtual visits to deliver ambulatory health care. Despite widespread adoption, there has been limited evaluation of the quality of care being delivered through virtual modalities for ambulatory care sensitive conditions (ACSCs). OBJECTIVE: To characterize patients' and providers' experiences with the quality and sustainability of virtual care for ACSCs. DESIGN: This was a multi-method study utilizing quantitative and qualitative data from patient surveys, provider surveys, and provider focus groups at a large academic ambulatory care hospital between May 2020 and June 2021. We included patients and providers utilizing telephone or video visits for the following ACSCs: hypertension, angina, heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma. MAIN MEASURES: Quantitative and qualitative patient and provider survey responses were mapped to the Six Domains of Healthcare Quality framework. Provider focus groups were coded to identify themes within each quality domain. KEY RESULTS: Surveys were completed by 110/352 (31%) consenting patients and 20/61 (33%) providers. 5 provider focus groups were held with 14 participants. Patients found virtual visits to be generally more convenient than in-person visits for ACSCs. The perceived effectiveness of virtual visits was dependent on the clinical and social complexity of individual encounters. Respondents reported difficulty forming effective patient-provider relationships in the virtual environment. Patients and providers felt that virtual care has potential to both alleviate and exacerbate structural barriers to equitable access to care. CONCLUSIONS: In a large academic ambulatory care hospital, patients and providers experienced the quality of virtual visits for the management of ACSCs to be variable depending on the biopsychosocial complexity of the individual encounter. Our findings in each quality domain highlight key considerations for patients, providers and institutions to uphold the quality of virtual care for ACSCs.

Development and assessment of a hospital-led, community-partnering COVID-19 testing and prevention program for homeless and congregate living services in Toronto, Canada: a descriptive feasibility study.

BACKGROUND: Outbreaks of SARS-CoV-2 in shelters and congregate living settings are a major concern because of overcrowding and because resident populations are often at high risk for infection. The objective of this study was to describe the development, implementation and assessment of the COVID-19 Community Response Team, a program that enabled Women's College Hospital in Toronto, Ontario, to work in partnership with shelters and congregate living settings to prevent outbreaks. METHODS: The Community Response Team, associated with Women's College Hospital, an academic ambulatory hospital, carried out mobile testing for SARS-CoV-2, supported outbreak management and prevention through ongoing onsite partnership with medical staff, and conducted infection prevention and control (IPC) training to shelter staff. We conducted a descriptive analysis of the sites supported by the program between Apr. 20, 2020, and Aug. 15, 2020. We also assessed the program's feasibility (number of completed needs assessments, mobile testing events and IPC training events, and median time from referral to service delivery), adoption (number of nasopharyngeal swabs, number of pre- and post-program outbreaks and IPC uptake) and acceptability or satisfaction. RESULTS: The Community Response Team supported 32 sites. Of those, 30 completed an intake needs assessment, 24 completed mobile testing for SARS-CoV-2 and 15 received IPC support. Mobile testing resulted in the collection of 1566 nasopharyngeal swabs, of which 64 were positive for SARS-CoV-2 infection. Three sites had confirmed outbreaks. The median time from referral to needs assessment was 4 days (interquartile range [IQR] 1-13 days), and the median time to the testing day was 9 days (IQR 1-49 days). The median time from referral to IPC staff training was 14 days (IQR 4-79 days), and 100% of respondents reported being pleased or very pleased with the training. During the follow-up period, the 3 facilities with outbreaks overcame those outbreaks. Three sites supported by the Community Response Team had further single cases, but no site reported subsequent or secondary outbreaks. INTERPRETATION: The Community Response Team program led to the transfer of IPC knowledge, allowed for the management and prevention of SARS-CoV-2 outbreaks, and demonstrated feasibility. Collaborative supports between hospitals and the community housing sector may serve as models for ongoing system integration beyond the COVID-19 pandemic.

Implementation and Evaluation of COVIDCare@Home, a Family Medicine-Led Remote Monitoring Program for Patients With COVID-19: Multimethod Cross-sectional Study.

BACKGROUND: COVIDCare@Home (CC@H) is a multifaceted, interprofessional team-based remote monitoring program led by family medicine for patients diagnosed with COVID-19, based at Women's College Hospital (WCH), an ambulatory academic center in Toronto, Canada. CC@H offers virtual visits (phone and video) to address the clinical needs and broader social determinants of the health of patients during the acute phase of COVID-19 infection, including finding a primary care provider (PCP) and support for food insecurity. OBJECTIVE: The objective of this evaluation is to understand the implementation and quality outcomes of CC@H within the Quadruple Aim framework of patient experience, provider experience, cost, and population health. METHODS: This multimethod cross-sectional evaluation follows the Quadruple Aim framework to focus on implementation and service quality outcomes, including feasibility, adoption, safety, effectiveness, equity, and patient centeredness. These measures were explored using clinical and service utilization data, patient experience data (an online survey and a postdischarge questionnaire), provider experience data (surveys, interviews, and focus groups), and stakeholder interviews. Descriptive analysis was conducted for surveys and utilization data. Deductive analysis was conducted for interviews and focus groups, mapping to implementation and quality domains. The Ontario Marginalization Index (ON-Marg) measured the proportion of underserved patients accessing CC@H. RESULTS: In total, 3412 visits were conducted in the first 8 months of the program (April 8-December 8, 2020) for 616 discrete patients, including 2114 (62.0%) visits with family physician staff/residents and 149 (4.4%) visits with social workers/mental health professionals. There was a median of 5 (IQR 4) visits per patient, with a median follow-up of 7 days (IQR 27). The net promoter score was 77. In addition, 144 (23.3%) of the patients were in the most marginalized populations based on the residential postal code (as per ON-Marg). Interviews with providers and stakeholders indicated that the program continued to adapt to meet the needs of patients and the health care system. CONCLUSIONS: Future remote monitoring should integrate support for addressing the social determinants of health and ensure patient-centered care through comprehensive care teams.

Operationalizing and Evaluating Synchronous Virtual Group Health Interventions: Wide-Scale Implementation at a Tertiary Care Academic Hospital.

Group-based health interventions are an important component of health promotion and management. To provide continuity of care throughout the COVID-19 pandemic, our institution undertook a rapid pivot to delivering group-based health interventions via a videoconferencing service which was securely embedded into both the electronic medical record and the patient portal to sustainably address immediate health service delivery needs during the pandemic and beyond. In this paper, we (1) describe the institutionally driven operationalization of a system to provide integrated synchronous video group visits across our hospital and (2) present a proposed strategy to comprehensively evaluate outcomes regarding their implementation, quality, and impact. Lessons for other institutions and the potential future role of synchronous video group visits to enhance how care can be scaled for delivery are discussed.

Outpatient visit trends for internal medicine ambulatory care sensitive conditions after the COVID-19 pandemic: a time-series analysis.

BACKGROUND: The COVID-19 pandemic led to a dramatic shift in the delivery of outpatient medicine with reduced in-person visits and a transition to predominantly virtual visits. We sought to understand trends in visit patterns for ambulatory care sensitive conditions (ACSCs) commonly seen in internal medicine clinics. METHODS: We included adult outpatients seen for an ACSC between March 15th, 2017 and March 14th, 2021 at a single-centre in Ontario, Canada. Monthly visits were assessed by visit type (new consultation, follow-up), diagnosis, and clinic. Time series analyses compared visit volumes pre- and post-pandemic. Proportion of virtual visits were compared before and during the pandemic. Patient and visit factors were compared between in-person and virtual visits. RESULTS: 8274 patients with 34,021 visits were included. Monthly visits increased by 15% during the pandemic (p <  0.0001). New consultations decreased by 10% (p = 0.0053) but follow-up visits increased by 21% (p <  0.0001). Monthly heart failure visits increased by 43% (p <  0.0001) whereas atrial fibrillation visits decreased. Pre- pandemic, < 1% of visits were virtual compared to 82% during the pandemic (p <  0.0001). Less than half of heart failure visits were virtual whereas > 95% of diabetes visits were virtual. CONCLUSIONS: We found a significant increase in overall visits to internal medicine clinics driven by increased volumes of follow-up visits, which more than offset decreased new consultations. There was variability in visit trends and uptake of virtual care by visit diagnosis, which may indicate challenges with delivery of virtual care for certain conditions.

A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic.

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.

Delivering Mental Health Care Virtually During the COVID-19 Pandemic: Qualitative Evaluation of Provider Experiences in a Scaled Context.

BACKGROUND: Virtual care delivery within mental health has increased rapidly during the COVID-19 pandemic. Understanding facilitators and challenges to adoption and perceptions of the quality of virtual care when delivered at scale can inform service planning postpandemic. OBJECTIVE: We sought to understand consistent facilitators and persistent challenges to adoption of virtual care and perceived impact on quality of care in an initial pilot phase prior to the pandemic and then during scaled use during the pandemic in the mental health department of an ambulatory care hospital. METHODS: This study took place at Women's College Hospital, an academic ambulatory hospital located in Toronto, Canada. We utilized a multimethods approach to collect quantitative data through aggregate utilization data of phone, video, and in-person visits prior to and during COVID-19 lockdown measures and through a provider experience survey administered to mental health providers (n=30). Qualitative data were collected through open-ended questions on provider experience surveys, focus groups (n=4) with mental health providers, and interviews with clinical administrative and implementation hospital staff (n=3). RESULTS: Utilization data demonstrated slower uptake of video visits at launch and prior to COVID-19 lockdown measures in Ontario (pre-March 2020) and subsequent increased uptake of phone and video visits during COVID-19 lockdown measures (post-March 2020). Mental health providers and clinic staff highlighted barriers and facilitators to adoption of virtual care at the operational, behavioral, cultural, and system/policy levels such as required changes in workflows and scheduling, increased provider effort, provider and staff acceptance, and billing codes for physician providers. Much of the described provider experiences focused on perceived impact on quality of mental health care delivery, including perceptions on providing appropriate and patient-centered care, virtual care effectiveness, and equitable access to care for patients. CONCLUSIONS: Continued efforts to enhance suggested facilitators, reduce persistent challenges, and address provider concerns about care quality based on these findings can enable a hybrid model of patient-centered and appropriate care to emerge in the future, with options for in-person, video, and phone visits being used to meet patient and clinical needs as required.

Correction: Building Health Services in a Rapidly Changing Landscape: Lessons in Adaptive Leadership and Pivots in a COVID-19 Remote Monitoring Program.

[This corrects the article DOI: 10.2196/25507.].

Adoption, feasibility and safety of a family medicine-led remote monitoring program for patients with COVID-19: a descriptive study.

BACKGROUND: Virtual care for patients with coronavirus disease 2019 (COVID-19) allows providers to monitor COVID-19-positive patients with variable trajectories while reducing the risk of transmission to others and ensuring health care capacity in acute care facilities. The objective of this descriptive analysis was to assess the initial adoption, feasibility and safety of a family medicine-led remote monitoring program, COVIDCare@Home, to manage the care of patients with COVID-19 in the community. METHODS: COVIDCare@Home is a multifaceted, interprofessional team-based remote monitoring program developed at an ambulatory academic centre, the Women's College Hospital in Toronto. A descriptive analysis of the first cohort of patients admitted from Apr. 8 to May 11, 2020, was conducted. Lessons from the implementation of the program are described, focusing on measure of adoption (number of visits per patient total, with a physician or with a nurse; length of follow-up), feasibility (received an oximeter or thermometer; consultation with general internal medicine, social work or mental health, pharmacy or acute ambulatory care unit) and safety (hospitalizations, mortality and emergency department visits). RESULTS: The COVIDCare@Home program cared for a first cohort of 97 patients (median age 41 yr, 67% female) with 415 recorded virtual visits. Patients had a median time from positive testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to first appointment of 3 (interquartile range [IQR] 2-4) days, with a median virtual follow-up time of 8 (IQR 5-10) days. A total of 4 (4%) had an emergency department visit, with no patients requiring hospitalization and no deaths; 16 (16%) of patients required support with mental and social health needs. INTERPRETATION: A family medicine-led, team-based remote monitoring program can safely manage the care of outpatients diagnosed with COVID-19. Virtual care approaches, particularly those that support patients with more complex health and social needs, may be an important part of ongoing health system efforts to manage subsequent waves of COVID-19 and other diseases.