Table 4 Emerging themes and quotes
Facilitators | Barriers | |
|---|---|---|
DECISION-MAKING FOR VIRTUAL VS. IN PERSON CARE | Preference for virtual care: Strongly believes in and was using virtual care before the pandemic “After decades of advocating for improved remuneration and resource support for virtual care of frail persons, the COVID-19 pandemic has finally introduced changes to support virtual care. Finally! Now to see if these essential supports remain” | Preference for in-person care: Does not feel a need for virtual care “I learn a great deal more in person” “We just did it because of COVID. No particular strategy, just necessity!” |
Considering virtual care as an alternative care: Finds phone appointments convenient, prefers mixed care, or sees virtual care especially useful for supporting family/caregiver “Often when it comes to dementia, most things can be discussed over the phone” “Appropriate mix of virtual and direct care, not abandoning direct care/visits” “Mostly helpful with caregivers and reduces their burden by improving convenience for them” | Uncertainty about post-pandemic regulations: Uncertainty about what will happen post-pandemic “Actually, uncertain if clinic will continue to provide” “[use it after the pandemic] No, absolutely not…government is very combative and non-collaborative and do not care of about our livelihoods and the considerable risk we are all taking working in our clinics to maintain financial stability in a pandemic” | |
Reception from PLWD/caregivers: Buy in from patients and caregivers “Patients understanding and supporting this method of care” “Willingness on the patients/family to engage this way. I find if offered most families are keen” “A strong patient-physician relationship and connection with family members” | Demand from PLWD/caregivers: High expectations from patients and caregivers “Patients have been booking for frivolous concerns because they know they can get us on the phone” | |
PREPARATION FOR VIRTUAL CARE ONCE AN APPOINTMENT MADE | Logistic support from office staff: Nursing, social worker, secretarial support for obtaining consent, providing instructions, and sending reminders prior to virtual appointment, organizing virtual visits “Clear written information helps, initial email with simple, clear instructions” “Using the social worker to set up and organize the meetings” “I work in a private virtual walk-in clinic, and the nature of visits are screened at intake. Also, the main people accessing the platform are working able-minded individuals who have coverage through their work benefits” | Consent and confidentiality issues: Problems may arise when patient and caregiver are together “Need to get the caregiver on the phone and then the patient, consent sometimes can be an issue this is a tough group to get accurate information from as the spouse is often afraid to speak in front of the person with dementia” |
EXECUTION OF VIRTUAL CARE | Family/caregiver presence: Engagement of family members or caregivers to assist with and participate in the appointment “Both patient and family/caregiver on the meeting at the same time” “Family member is engaged, and coordinates calls etc.” “Usually, I ask for family member to accompany for collateral information and support through the assessment” | Patients’ sensory problems: Hearing, seeing, communication problems “There are many cases when virtual care is extremely challenging for these patients (they can’t hear, they can’t see, they forget, they are not tech savvy, etc)” |
Availability and quality of technology: Videoconference, Zoom, iPad, Internet access “Good techno, [I] got built into my EMR” “Teleconference zoom video conference” | Poor quality of technology: Poor technology and connection problems “The phone and video connection where so poor that we abandoned the assessment after 20 min. This will not work in our rural area” | |
Technical support from office staff: Setting up and fixing technological issues “Thank goodness for RNs that have to figure out the glitches to making OTN and Microsoft teams run. Rural patients have been a particular difficulty” “Supports through my Academic clinic (secure video, access to an RN)” | ||
Existing telemedicine networks: Province had already a telemedicine system working “OTN - I was already registered” “Ongoing government support for remuneration and resources (secure web platforms and email)” | Lack of technological skills: Inability to use technology, especially patients “The patient with dementia often can’t manage any of these systems” “I figure out what works for each patient and/or caregiver. It’s mostly by phone, with some in person as needed. Rarely can patients manage the video aspect” | |
Peer support on how to use virtual platforms: FPs receiving support from FPs in other provinces “Support from doctors of BC to get training in virtual care platforms. Easy to use these platforms” | ||
PHYSICIAN COMPENSATION FOR VIRTUAL CARE PROVISION | Appropriate remuneration: Payments for virtual care “Government remuneration for phone appointments has removed a barrier” “Billing codes that allow for this, and appropriately compensate with time modifier increments” “I think virtual care is wonderful. There are a lot of things that I don’t physically need to see that patient for, and it can be difficult to get elderly patients to the clinic. The major and only factor that has enabled me to do this is the fee code. I would certainly not offer virtual care if I was not compensated for it” | Inadequate remuneration: Does not find renumeration enough “Virtual care is very poorly compensated, and we cannot financially survive providing it. It is very convenient to patients, and they have become very entitled accepting everything to be solved over virtual care when we can only be compensated for the first 10 min” |