“I would have to walk around to find the best Wi-Fi connection…”: qualitatively exploring challenges associated with rapid rollout of telehealth in Canadian long-term care homes

Abstract

Background

Early in the COVID-19 pandemic, long-term care (LTC) homes in British Columbia, Canada, restricted visitation to ensure the safety of their residents against transmission of the novel coronavirus. As such, these LTC homes had to quickly implement a rapid rollout of telehealth services to maintain physician care for residents while avoiding the infection risk of in-person visits amidst lockdown measures. The abrupt transition from traditional in-person physician care to telehealth presented significant challenges. Investigating these challenges is pivotal to the development of strategies for sustained telehealth use for physician services in LTC homes. This analysis is part of a broader qualitative, utilization-focused evaluation study of telehealth services rapidly implemented for physician care in LTC homes within the Fraser Health Authority region of British Columbia. The evaluation has aimed to consider integral factors such as telehealth challenges, facilitators, preferences, and continued use. Semi-structured interviews and focus groups were conducted with 70 physicians, staff, residents, and family caregivers across 27 different LTC homes in the region. All interviews and focus groups were transcribed verbatim and were analyzed using a thematic approach to identify common barriers surrounding the rapid rollout of telehealth in LTC across relevant groups.

Results

From the data, four challenges were identified: connectivity challenges (e.g., inconsistent or no Wi-Fi or cellular connectivity), device challenges (e.g., lack of accessible devices and software issues), privacy challenges (e.g., lack of private space to support telehealth use), and informational challenges (e.g., lack of electronic medical record access). All challenges posed barriers to telehealth access for both care provider and recipient groups in LTC settings.

Conclusions

The challenges identified in this analysis are supported by existing literature, which is significant given the different contexts within which such research has been undertaken. Collectively, this knowledge base can support evidence-informed improvements to telehealth for physician care in LTC settings. Future research should capture the perspectives of diverse cultural groups, LTC residents with cognitive impairments, and those who provide and receive care in rural settings.

Background

Long-term care (LTC) homes—also known as nursing homes, personal care homes, or residential care facilities [1] – provide round-the-clock on-site health and personal care for people with complex medical care needs who are no longer able to live independently [1, 2]. LTC often houses people who are 65 and older, many of whom have chronic conditions such as physical or cognitive impairments, including dementia [3]. Within the Canadian province of British Columbia (BC), LTC homes have care teams that are equipped to deal with the complex medical needs of the residents, including nurses, physical therapists, and social workers [4, 5], along with a dedicated physician [6]. The nature of these teams, and the size of the home, depends greatly on their jurisdiction and ownership. Within BC, approximately one-third of LTC homes are publicly funded and run by the regional health authority that administers publicly funded care where they are located [7]. Fraser Health is one such regional authority, which serves the largest number of British Columbians of any regional health authority in the province and is the focus of the current analysis [8].

The effects of the COVID-19 pandemic were devastating for Canada’s LTC homes, with this care sector seeing virus outbreaks and subsequent deaths in homes throughout the country [9,10,11]. Early research emerged showing that LTC residents often have health complications that put them at an increased risk of severe infection or even death after contracting COVID-19 [12]. In comparison to other countries, Canada’s LTC sector had the highest proportion of deaths related to COVID-19 reported globally [13]. Within BC, the greatest number of deaths and outbreaks happened in LTC homes within the Fraser Health Authority region [7]. In an attempt to control outbreaks and lessen viral spread, particularly prior to the arrival of vaccines, health care jurisdictions across Canada implemented policies to restrict visitation to LTC homes in order to protect residents and staff alike [10]. Within the Fraser Health region, these ‘lockdown’ protocols included heavily restricting family and friend visits, limiting opportunities for staff to work in more than one LTC home, and reducing in-person visits from physicians and other health care providers [14,15,16].

To support access to physician care for residents during COVID-19-related care home lockdowns, telehealth was rapidly rolled out by LTC sector administrators in many jurisdictions in BC, including by the Fraser Health Authority [17]. Telehealth involves providing medical care through methods such as video and phone calling, emailing, and texting and is a type of virtual care [18]. Traditionally, telehealth was used as a supplementary mode of care delivery in LTC homes, with in-person family physician and specialist appointments being the norm [19, 20]. At the outset of the COVID-19 pandemic, however, the preferred mode of medical care rapidly shifted to providing even the most routine physician consults by telehealth to limit the movement of non-essential people into and out of care homes [21,22,23]. The rapid nature of the rollout of telehealth in LTC homes as a measure to protect residents’ health left little opportunity for evidence-informed planning, such as ensuring infrastructure readiness to support this mode of care delivery. There is opportunity now, however, to retrospectively evaluate this rapid rollout period to identify experienced challenges that can inform thinking and planning around the continued use of telehealth in LTC homes to support physician care. Such research is of critical importance given the number of physicians across Canada who indicate an intention to substantially maintain or increase care provision via telehealth relative to pre-pandemic rates [24], including within LTC contexts [25].

The analysis presented herein qualitatively identifies and explores four critical challenges experienced during the rapid rollout of telehealth in Fraser Health’s LTC sector in response to visitation restrictions, including by physicians, to minimize COVID-19 spread. Importantly, we triangulate the experiential perspectives of two groups: care providers (i.e., front-line LTC staff and physicians) and care recipients (i.e., LTC residents and family caregivers). While there is some existing literature that engages with understanding challenges and barriers to telehealth uptake in LTC (e.g., [26,27,28]), it heavily draws from the care provider perspective or uses quality indicators that have been gathered without direct engagement of relevant groups. The current analysis thus presents novel insights while also contributing to a larger utilization-focused evaluation anchored around three objectives that will ultimately mobilize the findings directly to LTC leadership in the Fraser Health region to support experientially informed, recipient-centred, and provider-engaged approaches to sustained telehealth use for physician care in this sector.

Methods

The current analysis contributes to a qualitative evaluation study of the rapid rollout of telehealth care in LTC during the COVID-19 pandemic within the Fraser Health region. The objectives of the larger evaluation study were to: (1) explore residents’ and family caregivers’ experiences of receiving physician care by telehealth, including their preferences for such care in LTC homes; (2) examine physicians’ and health care providers’ experiences of coordinating and delivering care by telehealth and their preferences for doing so post-pandemic; and, (3) develop actionable tools to address identified facilitators and challenges to inform an equitable telehealth physician care program that is person-centred, coordinated, and value-based. Patton’s (2008) 12-step utilization-focused evaluative process informed our design, whereby steps look at readiness to evaluate; evaluator readiness; engagement of end users; situational analysis; identifying end users; defining evaluative scope; choosing techniques; piloting techniques; collecting data; analyzing data; knowledge mobilization; and reflection [29]. Utilization-focused evaluation focuses on collaboration between specific end-users and researchers to ensure that findings are useful and relevant for future decision-making [29]. Initial steps in the evaluation process identified the relevant groups consulted in the current analysis to be important knowledge holders. They also led us to partner with the Fraser Health Long-Term Care and Assisted Living Research Partners Group – a research advisory group of LTC residents, family members, volunteers, and staff – to ensure we maintained a focus on the intended use of telehealth for physician care by intended users. Our research team thus consisted of health services and LTC researchers who span academic and health authority contexts, as well as the relevant groups involved in this advisory group.

Our conceptual approach to understanding the domains of significance related to facilitating the implementation and use of telehealth in LTC for this utilization-focused evaluation was informed by Canada Health Infoway’s Benefits Evaluation – Clinical Adoption Framework [30]. This Framework identifies two scales of factors that are critical to the adoption of telehealth for physician care in practice settings [30]:

• (1) micro-level-factors: health information system quality (performance of the online systems), usage quality (user satisfaction and usefulness), and net benefits (care quality, access and availability of services, and productivity); and

• (2) meso-level-factors: people (who was involved and their roles), organization (strategy, culture, structure, infrastructure), and implementation (project management and adoption).

These scales of factors intersect with the four components of the Quadruple Aim of health system strengthening, which is to improve patient and caregiver experiences, health, health care costs, and quality of work life for health workers [31, 32]. We thus viewed data collection as an opportunity to contribute important insights into more meaningfully addressing the quadruple aim in LTC settings through the lens of telehealth use in this care context at the micro- and meso-level.

To explore the differing perspectives on facilitators and barriers to the implementation and use of telehealth during the COVID-19 pandemic, four relevant LTC groups were identified in the initial steps of the evaluative process for primary data collection: residents, family caregivers, providers, and physicians. Residents were those who resided in LTC homes in the Fraser Health region. Family caregivers were those involved in coordinating, supporting, or supplementing a resident’s medical care as a friend or family member. Providers were those who worked and assisted with telehealth use within LTC homes (e.g., Licensed Practical Nurses, Registered Nurses, Directors of Care, and Recreation Staff). Lastly, physicians provided medical care to residents in LTC via telehealth. We aimed to conduct both one-on-one (at least 5 per group) and dyad interviews (at least 5 pairs) with LTC residents and family caregivers, one-on-one interviews with LTC providers (at least 20), and a single focus group with physicians (6–10 participants). Overall, we aimed to recruit at least 50 participants across the four relevant groups consulted in this evaluative study, using a temporal cut-off of a six-month data collection period that reflected the time made available by our health system partners to support this evaluation and our research resources.

All participant groups were recruited over a six-month period in 2023. To recruit residents, family caregivers, and staff emails were sent to Nurse Managers in each of the 83 LTC homes in the Fraser Health region describing the study and asking for information to be shared with potential participants. To recruit physicians, emails were sent to Facility Medical Directors in the 83 homes inviting participation. Nurse Managers and Facility Medical Directors were also able to request posters that could be put up in appropriate spaces (break rooms, family member visiting areas, etc.). All recruitment materials were in English but could be requested in French, Korean, Punjabi, Farsi, Spanish, Chinese, and Vietnamese, which are all common languages in the region. The study was also advertised via a health research participant recruitment website, REACH BC. In addition to sharing study details and research team contact information, all recruitment tools noted a CAD$50 honorarium upon completion of the interview or focus group.

Eligibility to participate in the study was relatively straightforward. Residents had to be cognitively able to provide informed consent and be living in a LTC home where telehealth for physician care had been made available. Family caregivers were unpaid and untrained carers who had supported telehealth use for a resident. For dyad interviews, caregivers had to have been providing this support for the participating resident. Providers had to have had direct experience supporting the use of telehealth for physician care. Finally, physicians had to have direct experience in using telehealth to deliver medical care to residents. The overriding geographic inclusion criterion was that all participant groups had to have had this involvement in a LTC home in the Fraser Health region.

Semi-structured interview and focus group guides were created for each participant group, with questions being informed by Canada Health Infoway’s Benefits Evaluation – Clinical Adoption Framework and the Quadruple Aim of health system strengthening. These guides are available in the supplementary file attachment. Interview guides for all groups started with demographic questions as well as an assessment of digital literacy. This assessment was done via administering the standardized Digital Health Literacy Scale, which assesses one’s ability to independently use technology and solve technological issues by a three-item, five-point Likert scale [33]. The focus group was held virtually following a virtual administrative meeting among LTC physicians so as to facilitate participation. One-on-one and dyad interviewees had the option of participating virtually, by phone, or in person in the care home based on personal preference. An audio recording device was utilized to record phone and in-person interviews, while virtual interviews and the focus groups were recorded using Microsoft Teams. Interviews and focus groups were administered following participants providing oral consent to participate in the study. Interviews typically lasted 20–30 min, while the physician focus group ran for an hour. Interviewers were a group of trained research assistants led by the first author.

All interview and focus group recordings were transcribed verbatim using a professional service. The lead author reviewed transcripts for completeness and resolved any inconsistencies before analysis. To facilitate analysis, anonymized transcripts were imported into NVivo for data management. A thematic approach to analysis was employed, informed by Braun and Clark’s design [34]. First, members of the Fraser Health Long-Term Care and Assisted Living Research Partners Group were each assigned 3–4 transcripts to independently review. This review focused on identifying expected and unexpected experiences shared in the interview and focus group discussions. Group members then met to identify important and meaningful directions for analysis with members of the research team. Members of the research team iteratively used insights from this meeting, ongoing conversations about analytic possibilities documented in fieldnotes and shared in team meetings throughout data collection, and their own independent transcript reviews to ultimately identify three meta-themes to be explored through thematic analysis. These preliminary (i.e., pre-coding) meta-themes were presented back to the Long-Term Care and Assisted Living Research Partners Group to reinforce best practices for engagement and to enhance rigour via triangulation.

Following identification and confirmation of the meta-themes that could serve as directions for thematic analysis, a coding tree was created and organized around themes and sub-themes. These themes and sub-themes were both inductive and deductive, reflecting insights from the triangulated process of identifying the meta-themes as well as the questions probed in the semi-structured guides. The research team worked together to create this coding scheme, with the first author conducting the coding. A single coder was used to enhance consistency, but any uncertainty regarding interpretation was taken back to the research team by the coder to ensure consensus. Consistent with thematic analysis, upon completion of coding the team returned to the literature to identify existing research closely aligned with the meta-themes to facilitate consideration of the scope and scale of each as it related to the evaluative study and the novelty of the related findings. Following this, the team worked to assign the coded data to the meta-themes. In the remainder of this paper, an analysis of one of the meta-themes, challenges with rapid virtual physician care roll-out and adoption in LTC, is presented. The other meta-themes will be presented in separate analyses. This analysis draws upon four themes coded for within the dataset around the challenges meta-theme. Verbatim quotes are integrated to support the interpretation of these themes and enhance rigour via authenticity.

Results

A total of 70 people participated in this study across the relevant groups: residents (n = 26), family caregivers (n = 13), care staff (n = 16), and physicians (n = 15). Participants lived, worked, or supported care in 27 of the 83 LTC homes (32.5%) in the Fraser Health region. Forty-two identified as women (60%), 27 as men (39%), and one as non-binary (1%). Table 1 expands on the demographic characteristics of care recipients (residents and caregivers). Table 2 shares details on formal care provider groups (care staff and physicians).

Table 1 Demographic information of care recipients

Table 2 Demographic information of care providers

Thematic analysis of the interviews and focus groups identified four primary challenges that were experienced during the rapid rollout of telehealth in LTC for physician care as a protective measure during the COVID-19 pandemic. These challenges were related to connectivity, devices, privacy, and information. In the sections that follow, we expand upon these challenges, offering first-hand insights from participants. Though we consider each challenge separately, we acknowledge that there are interconnections and expand upon some of these in the discussion section.

Connectivity challenges

The most commonly discussed challenge that negatively impacted the effective provision of telehealth for physician care was the immense gap in Wi-Fi and cellular infrastructure present in LTC homes relative to the level of connectivity required to actually support virtual visits. In fact, many participants indicated that they were living or working in LTC homes with no Wi-Fi connectivity. Workarounds had to be quickly identified and implemented. In one example, a care staff detailed that their LTC home was using work phones with cellular data to support telehealth in the absence of Wi-Fi. Cellular infrastructure was also not seamless throughout the region. As another participant explained: “If I said I wanted to speak to a doctor, I would call from home because I couldn’t risk calling from the facility.” Many physicians shared that LTC buildings were typically old and, as a result, they had issues connecting virtually, if at all. The sentiment “the homes cannot support a lot of the technology that we want to use” was echoed by many.

Connectivity inconsistencies were commonly reported in LTC homes that had existing infrastructure to support telehealth. Numerous participants, for example, described encountering functional and dead zones for both Wi-Fi and cellular connectivity. Consequently, there was a consistent movement of staff and residents alike within homes to find a strong enough connection to support a telehealth visit, which negatively impacted on-site strategies to reduce COVID-19 transmission. In one instance, a caregiver described having to “walk outside the building in order for it [connection to a care conference] to work many times.” A care staff member shared a similar experience: “my Care Manager would have to move her computer around to see where she would get the [connectivity] bars. Sometimes, when I was doing meetings, I would have to walk around to find the best Wi-Fi connection.” Staff movement of this kind was not ideal as it often took them away from the resident they were supposed to be on the call with, as in many cases residents faced mobility restrictions. Participants also explained how the search for connectivity also posed time management implications, taking them away from other critical tasks as they looked for an area with Wi-Fi or cellular reception.

Device challenges

Participants felt there were not enough existing online capable multimedia devices, such as tablets and mobile phones, available in LTC homes to sufficiently support the rapid rollout of extensive telehealth for physician care. Many residents discussed how devices made available by care homes were often already in use when they needed them or required them to relocate to common areas for virtual appointments due to internal protocols. Care staff from multiple LTC homes expressed that facilities were simply unprepared when it came to ensuring device accessibility for telehealth. A common problem was coordinating device use. This was particularly problematic for homes with large resident populations. One care staff explained that “we could have used an additional laptop or tablet because we only had one per floor and have seven floors.” Physicians reiterated that many of the homes they visited did not have the appropriate technology to support telehealth. For example, reports of the lack of devices that allowed taking and sending photos during telehealth visits were numerous. This led some staff to use personal devices to facilitate taking and transmitting photos, which physicians noted raised significant privacy issues.

Software access compounded the device availability challenges reported by participants. For example, participants discussed how preferred platforms, such as FaceTime, were not commonly available on devices owned by LTC homes. Others reported software updates not being initiated resulting in Zoom calls failing. As a care staff who worked in multiple LTC homes explained: “it's not very efficient when the softwares [sic] and things are not kept up to date. And if the devices become old or there's some issues with it, care facilities sometimes don't know that.” External devices owned by family caregivers that connected to telehealth meetings also ran into issues, which created problems for telehealth. Staff reported troubleshooting challenges that emerged when family members joined telehealth appointments remotely. A family caregiver discussed how “the sound quality of the [telehealth] meeting wasn’t that good. And it could be our fault because our computer is old.” Overall, device age limitations and software absence or inaccessibility consistently challenged telehealth use for physician visits across all participant groups.

Privacy challenges

Private spaces for telehealth meetings were not available in every care home. One caregiver noted they did not feel comfortable sharing personal health details with a physician during a phone call in the care recipient’s room because a roommate could listen in. Numerous participants echoed such privacy concerns. Even if a home had private space available for telehealth, not all residents were mobile enough to be relocated. An administrator explained that “if the resident can come to my office…we'll do it in there. But there are some residents that don't like to leave their room, or because of function and pain, they don't do well in their wheelchair.” Private bedrooms with doors that could close were viewed as optimal spaces for telehealth: “We had no noise and distractions because we were in a private resident room.” Noise distractions in non-private spaces were seen as highly disruptive, especially for residents with cognitive impairments. Some care staff also felt they found it hard to fully focus on supporting telehealth appointments when there were a lot of disruptions in the background.

Many participants discussed having access to private spaces outside of residents’ rooms in LTC homes, but it was suggested that many of these spaces could not support telehealth meetings effectively. Prior to the COVID-19 pandemic, these spaces were used for in-person checkups and medical visits. It was uncommon for these rooms to have been outfitted to support virtual appointments, and thus they typically had poor Wi-Fi connectivity. This issue was particularly problematic for smaller care homes, as one care staff noted: “Our building is very small, so we had a real lack of privacy. When we identified a private area, we didn’t really have good Wi-Fi connection.” Many physicians indicated that they had to give up on video calls and switch to cellular calling into care conferences held in the LTC home due to poor Wi-Fi in private medical visitation rooms. This strategy took away the potential for visual interaction being supported by telehealth during these visits.

Informational challenges

A prevalent challenge reported by care providers was the unavailability of electronic medical records (EMRs) during the rapid rollout of telehealth. For some physicians, having access to EMRs created a streamlined process for being able to effectively monitor residents and have access to their medical histories when working off-site. However, not all homes supported EMR use, which led to increased informational discontinuity, given that opportunities for on-site care were extremely limited. This was especially true for LTC homes where patient charts were kept on paper, whereby remotely following “what was going on with people…was not an option” via virtual visits. Another physician went further to say that “there’s a very clear line in the sand that paper-based charts are terrible and do not support off-site access.” Several LTC homes in the region used paper charts at the point of rapid telehealth rollout, which created extensive care coordination and informational continuity challenges in the context of virtual physician visits.

The rapid rollout of telehealth within LTC homes prompted some sites to push EMR rollout simultaneously. One care staff highlighted their experience: “Our goal was to have an electronic medical system called eMAR, so they had our Wi-Fi bumped up. They thought it would work really well, and then the first day we started using the records, it crashed, and we haven’t gone back to using it again.” In this instance, the care home had to continue using paper charts despite knowing the impacts this would have on supporting telehealth for physician care. Experiences such as this one also pointed to the amplified demand that remote care placed on LTC homes with regard to Wi-Fi infrastructure in instances where it was strong enough to support telehealth.

Discussion

Contributing to a larger utilization-focused evaluation, the findings shared above highlighted the lived experiences of both care recipients and care providers within LTC settings during the rapid rollout of telehealth services for physician visits during the COVID-19 pandemic, with a focus on four types of challenges experienced. There are important interconnections between these challenges. For example, connectivity challenges, specifically reliable Wi-Fi access, proved to be a catalyst for contributing to other challenges. This included weak Wi-Fi access negatively affecting the functionality of online EMRs during telehealth visits while also not allowing for appropriate spatial privacy due to needing to avoid ‘cold zones’ during appointments. While device challenges were reported by all participant groups, care staff were particularly affected as it was their responsibility to keep a constant stream of communication between residents, their families, and physicians during the rapid rollout of telehealth and throughout the pandemic. The magnitude of how challenges were experienced and what their impacts were varied, with the size, layout, and age of LTC homes playing a key role in such variation. In the remainder of this section, we contrast the findings against existing knowledge to identify novel contributions while also considering implications for continuing telehealth use for physician care in LTC post-pandemic and for future research.

Connectivity issues have been highlighted as a substantial barrier that negatively affects telehealth use in other LTC studies. For example, two recent syntheses identified a lack of Wi-Fi connectivity to be a substantial barrier to effective telehealth use in LTC homes across a number of geographic contexts [21, 28]. Even more closely aligned with the current study, Mohammed and colleagues identified how, in another Canadian province, limited Wi-Fi connectivity negatively impacted the use of virtual care across all primary care sectors, including LTC, throughout the COVID-19 pandemic [35]. Further, our findings support prior research showing that Wi-Fi connectivity can be greatly affected by the age of an LTC home [36]. Device challenges have also been discussed extensively in related literature. A study conducted in a region of Ontario, Canada, noted that a number of LTC homes had to fundraise in order to purchase tablets for telehealth and social use by residents during the lockdown stages of the COVID-19 pandemic [26]. In some cases, the devices that were donated were older and did not fully support telehealth [26], which aligns with the device challenges commented on by participants of the current study. A focus group study of Canadian family caregivers in LTC during the COVID-19 pandemic further identified the lack of suitable technology and the inability of existing technologies to adapt to the needs of residents as substantial barriers to effective virtual visitations [37]. When coupled with the findings of this analysis and the larger utilization-focused evaluation study, this research can and should be collectively leveraged to call for improvements in Wi-Fi and device access and upkeep that can ultimately positively impact, for example, the maintenance of spatial privacy during virtual care in LTC homes.

One of the most significant challenges identified by participants was the lack of EMR use in LTC homes and how this negatively affected the provision of telehealth. Our interviews did not set out to probe EMR use, but it was a consistent talking point for care provider participants in particular. The connection between the presence of EMR use and the success of telehealth for physician care is not well established in the LTC literature on virtual care. A Canadian study examining family physicians’ experiences of delivering virtual care during the COVID-19 pandemic found that EMR access greatly facilitated such care provision [38]. Participants in the current study echoed this, though in the context of the care provided in LTC homes. The importance of having access to private space and facilitating such privacy to support telehealth use is another aspect of the findings of the current study that has received relatively little consideration in the LTC literature. Many homes, especially in Canada, have rooms that are not private [10, 39]. For this reason, best practices around providing privacy during virtual visits are not shared widely. One study notes that LTC residents may be fully content with using a conference room for telehealth meetings [40]; however, the transferability of such a practice is limited to homes with good Wi-Fi connectivity and device access. This was not the case for many LTC homes in the current study, where findings documented residents being moved into open, non-private spaces with good Wi-Fi access or even using care providers’ private devices on entranceways outside homes during appointments.

The findings of this analysis can be used to inform the identification of opportunities to reduce future challenges surrounding the implementation and continuation of telehealth services in LTC for physician care. For example, the four challenges identified provide insight for LTC administrators in Fraser Health and beyond as to where additional capacity is needed within LTC homes to support telehealth use for physician visits as a continuing strategy, which is an objective of the larger utilization-focused evaluation. One example is to identify a space in all LTC homes with stable Wi-Fi and up-to-date technology and software that can be available for telehealth and is maintained for this purpose. Doing so may avoid the fairly consistent movement of both residents and staff within homes reported during this study. While such movement may have been an unintended consequence of rapid rollout, the pace and timelines regarding supporting the continuing use of telehealth in this care sector can involve planning to undo these short-term relocations and the harm they had to residents’ privacy. Among other factors, planning for dedicated telehealth spaces will allow for minimizing trip hazards by ensuring that dedicated telehealth spaces can accommodate medically fragile residents [41]. Overall, better supporting telehealth use in LTC can assist with preparing this sector for health emergency management in relation to climate emergencies that limit access to care sites by physicians and others [42]. Floods, wildfires, and extreme heat have all negatively impacted LTC homes in Fraser Health in recent years, which serves to underscore the importance of being able to provide telehealth options for residents and physicians alike [43]. Finally, many Canadian physicians have expressed a desire to continue to use telehealth services that were rolled out rapidly during the COVID-19 pandemic [24, 35, 44], and so preparing LTC support this care medium into the future is responsive to providers’ requests.

Many important directions for future research emerge from this analysis, three of which we highlight here. First, this analysis has explored challenges that were experienced due to the rapid rollout of telehealth across Fraser Health’s LTC sector. It would be very meaningful to explore the opportunities that emerge through the use of telehealth in LTC homes from the same relevant groups consulted in the current analysis. An analytic direction of this nature from the current dataset would directly support the objectives of the larger utilization-focused evaluation, while also allowing triangulated consideration of the challenges identified herein to support actionable solutions. Such insight can support larger, dedicated exploration as to whether or not the opportunities presented using telehealth are substantial enough to warrant the financial and resource investment needed to overcome the challenges identified herein. Second, LTC staff consistently discussed how they were expected to facilitate successful telehealth interactions through getting residents into spaces that could support connectivity, preparing devices, and often initiating appointments. It would be useful for future research to consider informational tools and innovative resources to support inclusive and sustained telehealth for staff and residents with diverse needs, including those living with dementia in LTC homes. For example, telepresence robots, as detailed by Hung and colleagues could expand on their potential to provide support for telehealth, contributing to inclusivity of care [45]. This research should also consider factors such as training, time availability, and best practice. Finally, there is the potential for the barriers identified in the current analysis to be transferrable to other contexts. Many assisted living apartments, which are residences for residents – primarily older adults – who can live independently but require functional care support, and other residential nursing care settings across Canada supported telehealth use by residents during the COVID-19 pandemic [46], and thus, the presence of the challenges identified in the current analysis should be explored in these contexts. Similarly, research exploration of the ways in which the challenges identified in the current analysis have been addressed in differing jurisdictions, including areas with fewer health system resources or dissimilar LTC sector structures, would be very useful in terms of identifying directions for solutions that have yet to be considered in Canadian contexts.

Strengths & limitations

This analysis has several strengths. Most significantly, we gathered perspectives from both care recipients and providers that allowed for a robust analysis of both sides of the care process of telehealth use in LTC homes. Further to this, a sizeable number of LTC homes in the region of focus for this study were involved in data collection, which provided triangulated insight into similar challenges that were occurring across diverse homes in Fraser Health. We believe this, coupled with the contextual information provided about the rapid rollout in Fraser Health, enhances the transferability of the findings. Another strength is that we incorporated a partner-centered approach to data collection and analysis, where people who had close ties to LTC were involved in every stage of the research process. This ensured that the research would be applicable to end-users, informed appropriate language choices for interview materials, and identified meaningful directions for data collection.

There are limitations to our study, three of which we highlight here. First, many residents in LTC homes lack the cognitive capacity to consent to participate in a study such as this [47, 48]. As such, the voices of this majority resident group are underrepresented in the analysis. This means we have missed perspectives on how the rapid rollout affected those who were far into cognitive decline and their family caregivers, though no insights from care provider participant groups indicated that the experiences of this resident group were unique compared to others. Second, although we provided options for data collection to occur in languages other than English, this was requested only once. Fraser Health is an incredibly diverse region of BC, and it is likely that our participant group does not capture the ethno-linguistic diversity of LTC residents and care providers. Finally, residents stay in LTC for an average of approximately two years [49]. Because of this, our data collection will have substantially missed engagement with residents who experienced the earliest stages of telehealth rapid rollout during the COVID-19 pandemic. This limitation is not specific to our study and is more reflective of conducting evaluative and/or implementation research in LTC contexts.

Conclusions

The rapid rollout of telehealth in LTC settings across BC to support physician visits during the COVID-19 pandemic had immense benefits as it ensured the continuation of care during a time when in-person visitation was risky and thus discouraged. Despite these benefits, the rapid nature of the transition to using telehealth did not occur without challenges. This qualitative study has identified such challenges that were reported by four distinct relevant groups as part of a larger evaluation study. These challenges relate to connectivity, device use, privacy, and information access. Overall, we found that LTC homes throughout BC’s Fraser Health region were largely not adequately prepared for the quick shift from telehealth being a supplementary form of care to becoming the primary form of care. Addressing the challenges is imperative not only for strengthening telehealth practice in LTC sectors but also for ensuring that healthcare service systems are robust against future pandemics or climate emergencies requiring telehealth-enabled physician care.