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Abstract
Objective With the onset of the COVID-19 pandemic, telehealth case management (TCM) was introduced in primary care for patients requiring care by distance. While not all healthcare needs can be addressed via telehealth, the use of information and communication technology to support healthcare delivery has the potential to contribute to the management of patients with chronic conditions and associated complex care needs. However, few qualitative studies have documented stakeholders’ perceptions of TCM. This study aimed to describe patients’, primary care providers’ and clinic managers’ perceptions of the use of a nurse-led TCM intervention for primary care patients with complex care needs.
Design Qualitative descriptive study.
Setting Three primary care clinics in three Canadian provinces.
Participants Patients with complex care needs (n=30), primary care providers (n=11) and clinic managers (n=2) participated in qualitative individual interviews and focus groups.
Intervention TCM intervention was delivered by nurse case managers over a 6-month period.
Results Participants’ perceptions of the TCM intervention were summarised in three themes: (1) improved patient access, comfort and sense of reassurance; (2) trusting relationships and skilled nurse case managers; (3) activities more suitable for TCM. TCM was a generally accepted mode of primary care delivery, had many benefits for patients and providers and worked well for most activities that do not require physical assessment or treatment. Participants found TCM to be useful and a viable alternative to in-person care.
Conclusions TCM improves access to care and is successful when a relationship of trust between the nurse case manager and patient can develop over time. Healthcare policymakers and primary care providers should consider the benefits of TCM and promote this mode of delivery as a complement to in-person care for patients with complex care needs.
- Primary Health Care
- QUALITATIVE RESEARCH
- Telemedicine
Data availability statement
The data are not publicly available due to privacy and ethical restrictions.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The qualitative descriptive design provided an in-depth understanding of telehealth case management (TCM) from the perspective of those delivering and receiving the intervention.
The description of stakeholders’ perceptions on TCM in primary care for patients with complex care needs provides findings that can be transferred to similar settings.
Some interviews were conducted during waves of COVID-19 infections and may have impacted participant’s perception of TCM.
Introduction
Patients with a combination of physical and mental health conditions, drug interactions as well as social vulnerability are sometimes referred to as patients with complex care needs and they present the greatest challenges to the healthcare system and providers.1 This population can benefit from case management (CM) interventions with improved health outcomes.2 3 CM is a collaborative process of assessing patients’ and their families’ health needs, planning and coordinating their care with the use of available health and social resources. It involves examining patient care and health outcomes to improve quality of care and health, as well as system efficiencies.4
With the onset of the COVID-19 pandemic, it became necessary to use telehealth for healthcare delivery in primary care settings. There are multiple definitions of telehealth in the literature, with telehealth and telemedicine often being used interchangeably.5 The Health Resources and Services Administration (USA) defines telehealth as ‘the use of electronic information and telecommunication technologies to support long-distance clinical healthcare, patient and professional health-related education, health administration and public health’.6 For the purposes of our study, telehealth is defined as the use of telephone, text message, email and video conferencing in the delivery of healthcare, education and self-management support by distance. This definition does not include telemonitoring and ambulatory monitoring.
At the height of the pandemic, when public health measures and patients’ concerns about their safety restricted access to primary care settings, the use of telehealth was critical especially for patients with complex care needs, a population with the potential to benefit the most from continued remote care.7 8 The pandemic resulted in case managers having to modify their clinical practice to expand telehealth CM (TCM).9 Interestingly, in 2006, well before the COVID-19 pandemic, Park10 found that the use of TCM was growing with case managers who were some of the earliest providers to use telehealth. It has also been used by a variety of healthcare providers prior to 2020, due to its cost-effectiveness.5
Telehealth works well when administering CM because it facilitates more frequent and easier contact with patients.10 Specifically, telephone support used in CM has shown good potential in decreasing outpatient visits after discharge for patients with multiple complex conditions.11 A scoping review by Beland et al12 found that TCM was associated with lower healthcare costs and positive patient outcomes. Although lack of face-to-face contact was a noted drawback, overall delivery of CM interventions through telehealth was generally found to be effective and acceptable based on positive patient outcomes, such as better quality of care, improved mental health functioning and decreases in healthcare costs. A scoping review by Joo and Liu13 identified weaknesses and strengths of TCM for patients with chronic conditions. They reported that patients may face challenges in learning and using technologies and that TCM could increase workload for case managers. However, they documented that TCM has important benefits, such as providing efficient and timely care, improving access to care, increasing patients’ satisfaction and reducing healthcare costs. Both of these reviews included few qualitative studies documenting stakeholders’ perspectives on TCM and none captured the perspectives of multiple people involved within the same programme. This paper aims to describe patients’, primary care providers’ and clinic managers’ perceptions of a nurse-led TCM intervention for primary care patients with complex care needs.
Methods
Study design
This study was conducted as part of a larger research programme called PriCARE. This programme implemented CM in five Canadian provinces where a 12-month nurse-led CM intervention was carried out for patients with complex care needs within primary care settings.14 A qualitative descriptive design15 was used for this study to capture how patients, providers and clinic managers who were all participating in the same programme perceived TCM. This approach allowed the researchers to gather rich descriptions of TCM from the perspective of those delivering and receiving the intervention.16
Telehealth case management
The TCM intervention was developed from a CM intervention implemented in the PriCARE programme consisting of four components based on Canadian and American guiding principles17 18 and prior studies19–24 on CM in primary care for patients with complex care needs: (1) assessment of the patient’s needs and preferences; (2) codevelopment and maintenance of a patient-centred individualised service plan (ISP), that is, a plan created with the patient, family and other partners to coordinate services required to meet the patient’s life plan (goals and desired outcomes); (3) coordination of services among all partners and (4) education and self-management support for patients and families. The intervention was delivered by nurse case managers over a 6-month period, in collaboration with family physicians and other health providers, if needed. The nurse case managers received training on the intervention and motivational interviewing and were supported by clinical tools and an expert in CM, their health manager and the research team. The CM intervention implemented in the PriCARE programme is detailed elsewhere.14 The TCM intervention offered the same components as the main study but was offered by telephone, text message or email, as well as in-person when possible, to patients with complex care needs who were impacted by a disruption of services during the COVID-19 pandemic. Frequency of contact was determined by the nurse case manager and the patient. None of the people interviewed received or delivered TCM by video conferencing due to a lack of access to or interest from patients and providers in that mode.
Settings
This study was conducted within three primary care clinics, in three provinces: New Brunswick, Nova Scotia and Newfoundland and Labrador. The three primary care settings included: (1) a collaborative family health team comprised of family physicians, a nurse practitioner and a family practice nurse; (2) a collaborative family health team comprised of family physicians, nurse practitioners, registered nurses, licensed practical nurses and recreational therapists and (3) a teaching clinic associated with a medical school, with family physicians, medical students, registered nurses and licensed practical nurses.
Data collection
Participants were patients of primary care clinics (n=30) recruited for CM as well as clinic healthcare providers (n=11) and clinic managers (n=2) recruited through purposeful sampling.25 They were approached about the study by telephone or email by a research coordinator (ADP, DH and CS) responsible for data collection. In some cases, research coordinators had a prior relationship with healthcare providers and clinic managers because they worked together to implement CM in their clinics.
Patients enrolled in the study participated in a semistructured individual telephone interview. Healthcare providers comprised of family physicians, nurse practitioners, nurse case managers as well as a clinic manager based at the study’s primary care clinics participated in a semistructured individual telephone interview. A virtual focus group was held at one of the study primary care clinics with family physicians and a clinic manager. Individual interviews and the focus group were conducted by the research coordinators trained in qualitative interview methods. The interview guides were created by the research coordinators with feedback from study investigators and patient partners (online supplemental appendix 1 and 2). They included questions concerning the suitability of telehealth for the various components of CM, satisfaction with care received or delivered through different delivery modes as well as facilitators and challenges of TCM. The individual interviews conducted lasted between 30 min and 60 min and the focus group lasted 45 min. Interviews and the focus group were audio recorded and transcribed verbatim by a trained transcriptionist.
Supplemental material
Supplemental material
Data analysis
Methods of inductive thematic analysis were used to examine the interview and focus group data.26 The research coordinators who conducted the interviews developed a preliminary code book based on the study objectives and topics identified from a first read of the same three transcripts from interviews with different stakeholders. The code book was shared with the wider research team, including patient partners, to discuss code congruence with their sense of emerging themes. The team, including researchers and patient partners, met two times to discuss, refine and build consensus on the code book, adding codes and elaborating on code descriptions. The finalised code book was then used by the research coordinators to code all transcripts using NVivo V.12 server software (QSR International Pty) for data organisation and management (online supplemental appendix 3). Each transcript was coded by two coders and the coding team met several times to discuss and refine their coding approach. Coding reports were produced from NVivo V.12 and data were entered into a table, organised by theme and by participant type (patient or providers/nurse case manager/clinic manager).
Supplemental material
Patient and public involvement
Patient partners from the PriCARE research programme were involved in the following aspects of the current study: (1) development of the research objectives; (2) planning of the research design; (3) development and validation of data collection tools (ie, interview guides); (4) validation of data analysis tools (code book); and (5) drafting of the manuscript.
Results
Table 1 presents the characteristics of the participants. Most of the participants were women (70%) and a majority of patients were aged 65 and over (58%). Most of family physicians were represented among the health providers.
Characteristics of the participants (n=43)
Participants’ perceptions on TCM were captured in three themes, which are presented in the section that follows. Table 2 contains the illustrations to support the themes.
Overarching themes, subthemes and quotes that characterise patients, primary care providers and clinic managers’ perceptions of TCM
Improved patient access, comfort and sense of reassurance
Patients reported three main advantages of TCM. First, patients found that TCM facilitated their access to healthcare. It decreased time off work, did not require need for childcare and reduced waiting times associated with not having to physically attend appointments. Patients who face travel-related barriers in accessing their primary care clinic due to a lack of transportation, long travel time or distance, physical disabilities that limit mobility or other socioeconomic barriers to attending in-person appointments, appreciated TCM. They noted that receiving TCM allowed them to connect with a provider more easily and more frequently and was, therefore, an advantage and benefit to their care. Second, patients reported a greater sense of ease with TCM and the ability to attend appointments from their own home. They noted that in-person appointments can feel overwhelming when receiving multiple pieces of information regarding their health, while TCM appointments allow them to feel more relaxed and less pressured to think on the spot when asked questions by their provider or nurse case manager. Finally, TCM was reassuring to patients because it allowed them to receive healthcare without risking exposure to COVID-19, especially when rates of transmission and infection were high.
Providers identified two key advantages of TCM. First, they noted that organising care and resources for patients was very manageable and could be done well by TCM. Providers reported that service coordination and education and self-management support in particular were suitable aspects of CM to be delivered via telehealth. Second, providers noted that TCM enabled patients to carry out preventative healthcare activities such as blood pressure and glucose monitoring at home, thus increasing patients’ engagement in and management of their own health between medical appointments.
Trusting relationships and skilled nurse case managers
The success of TCM was largely dependent on trust between patients and their nurse case manager. Many patients spoke about their comfort with TCM as a result of their confidence and trust in the nurse case manager. Patients who reported greater satisfaction with TCM also reported feeling respected and understood by an engaged nurse case manager despite minimal face-to-face contact. According to both patients and providers, nurse case managers who are best suited to leading TCM are those who are clear in their communication, warm and personable, can manage expectations, and set reasonable goals with patients. An initial in-person meeting to review health needs and goals would help to build a trusting relationship between the patient and the nurse case manager. The initial meeting combined with the relationship that continued to develop over the course of the intervention helped them feel at ease with having less face-to-face interaction. Regular contact with the nurse case manager through telephone, email and text message enhanced patients’ perceptions of TCM more broadly and helped facilitated comfort with it. Patients reported that receiving email summaries of what was discussed during telephone appointments from the nurse case manager helped them review their progress and plan as well as increased their comfort with their care and their ability to self-manage through TCM. Although face-to-face appointments were viewed as valuable for rapport-building at the beginning of the CM intervention, many patients were comfortable with TCM as the dominant mode of delivery.
Overall, nurse case managers reported that their patients’ needs were being met and that they felt a connection to their patient via TCM. Participants noted that TCM appointments are more effective if a trusting relationship is already established between both parties. One nurse case manager mentioned that her patients reached out to connect by telephone to check-in and report on their health. She attributed this to an established relationship of trust and communication. Providers also reported that the nurse case manager’s comfort with their role, preparedness and clinical practices optimised the success of TCM. Carrying out advance work, such as keeping detailed notes and reviewing them before each follow-up with patients maximised the efficiency and effectiveness of telephone appointments. Nurse case managers reported that they tailored goals and supports to suit patient needs, often by keeping goals in TCM appointments manageable and ensuring that the support and community resources were provided in a way that suited individual patients’ capacity to use them.
Activities more suitable for TCM
Patient and provider interviews suggested that TCM is best suited to certain activities of the CM intervention including quick check-ins, follow-ups, prescription refills, patient reminders, service coordination and education and self-management support. Providers noted that in-person appointments are typically required for patients presenting with complex needs that require a physical hands-on assessment. Nurse case managers reported that initial assessment at in-take as well as the ISP meeting, which includes a wraparound service approach plan, is in most cases better executed in person. However, one nurse case manager did report that an ISP meeting could be done over the telephone, if needed. Some providers reported that the lack of face-to-face interaction can obscure visual cues relating to hygiene and posture that could reveal mental and physical health concerns. However, a number of participants noted that video conferencing could bridge this gap between what can be accomplished with in-person versus telephone visits.
Discussion
This study provides insight into how patients, primary care providers and clinic managers perceive TCM. It was a generally accepted mode of primary care delivery and worked well in most patient and provider experiences. Participants found TCM to be useful and a viable alternative to in-person care. All providers reported that TCM was an appropriate form of healthcare delivery for certain types of appointments that do not require physical assessment or treatment.
To our knowledge, this study is the first to describe different stakeholders’ perceptions of TCM in primary care for patients with complex care needs. The results are in line with other studies documenting perceptions of TCM for patients with chronic conditions. Kahn et al27 reported on a TCM programme that used telephone monitoring between office visits providing diabetes counselling and facilitated self-care with patient appointment reminders, lab work and specialty referrals. Patients were able to develop trust and rapport with nurses, often initiating phone calls themselves. Similarly, Schmidt et al,28 in a study of how elderly people with multimorbidities perceived a CM intervention using video conferencing, reported that rapport can be established when the case manager has the skill and the ability to promote a trusting environment. A trusting relationship between patient and nurse case manager can be developed by telephone,29 30 but no specific evidence in the current literature reported that this relationship has been successfully established for patients with complex needs, outside of face-to-face CM. This study shows that a relationship of trust could be developed with this population using a combination of in-person, telephone, email and text message for primary care visits.
TCM has grown in popularity over the past years and is likely to play a larger role in care delivery going forward given its cost-effectiveness and particular utility during the COVID-19 pandemic.10 Considering that the growing number of patients with complex care needs is likely to exceed the capacity of the healthcare system in the next decade; TCM appears to be a promising solution to greater efficiency in healthcare resource utilisation.31 32 Telehealth is best suited to patients with complex care needs who require continual care and represent a high proportion of people who frequently need healthcare services.13 This population reported many advantages for using telehealth, such as the convenience of having healthcare appointments in the comfort of one’s own home also reported in other studies, not having to travel, breaking social isolation and receiving timely and frequent communication.13 33–35 However, case managers have to consider that in-person appointments are still needed for patients requiring a physical hands-on assessment and are generally more appropriate for specific CM activities. Patients with complex care needs could benefit from a hybrid mode of delivery of care: telehealth for regular follow-up and face-to-face appointments for physical hands-on assessment, initial appointments and the ISP meeting. Healthcare policymakers should consider the benefits of TCM, promote this mode of delivery and improve access to TCM for this population.
This study had strengths as well as limitations. Several strategies were conducted to ensure trustworthiness of the study. The diversity in backgrounds of the authors’ (family medicine, nursing, public health, anthropology, international development and political studies) brought a variety of perspectives to the data analysis. The description of stakeholders’ perceptions on TCM in primary care for patients with complex care needs provides findings that can be transferred to similar settings.36 A limitation of this study was that the participating clinics did not offer video appointments as part of the TCM, so we could not report stakeholders’ perceptions of all possible modes of delivery. This was largely due to clinic infrastructure barriers and perceived lack of technological literacy of patients or desire to use video conferencing. The wider context of this research is important as some interviews were conducted during the height of second and third regional waves of COVID-19 infections. In turn, this may have impacted how patients responded to their comfort or lack thereof with in-person appointments, in particular, patients who were immunocompromised due to chronic conditions and/or experiencing challenges to their mental health. We must keep in mind that participants could also have in-person appointments, and it could be difficult to distinguish in-person and telehealth experiences. The interviews and focus groups were conducted by the research coordinators of the programme who did work with staff to implement TCM in providers’ and managers’ settings. This could have favoured their positive perception of the intervention.
Conclusion
TCM was generally perceived as positive and viewed as working well for most patients, primary care providers and clinic managers. TCM improves access to care and is successful when a relationship of trust between the nurse case manager and patient can develop over time. Healthcare policymakers and primary care providers should consider the benefits of TCM and promote this mode of delivery as a complement to in-person care for patients with complex care needs. Future studies could explore which factors influence implementation of TCM.
Data availability statement
The data are not publicly available due to privacy and ethical restrictions.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by New Brunswick the Research Ethics Boards at Horizon Health Network (#2018-2694) and University of New Brunswick (#016-2019); in Newfoundland and Labrador the Research Ethics Board at Memorial University (#20192572); and in Nova Scotia the Nova Scotia Health Research Ethics Board (#1024432). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The researchers would like to thank all the participants for their contributions to this research through interviews and focus groups. Thanks as well to patient partner team members who are actively involved in all aspects of the larger PriCARE program and who contributed to the development of this sub-study’s interview guides and codebook, commented on preliminary analyses and offered feedback on this manuscript: André Gaudreau, Cathy Scott, Donna Rubenstein, Judy Porter, Véronique Sabourin, Linda Wilhelm, and Mike Warren.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors CH, M-CC, KA-B, FB, SD, AD-P, CS and DH contributed to the study conception and design. CH and ML led the different steps of the study. AD-P, CS and DH conducted the data collection as well as the analysis and worked on the results summaries. The first draft of the manuscript was written by AD-P, CH, ML, CS and DH. MB, KA-B, FB, SD, AL, MM, JZ and JT commented on subsequent versions of the manuscript. All authors read and approved the final manuscript. CH is the guarantor.
Funding This study is supported by the Foundation for the advancing family medicine, CO-RIG phase I.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.