Background
Methods
Research design
Sample
Data collection
Data analysis
Trustworthiness and rigour
Results
Patients have reduced travel burden | |
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Patients have increased psychosocial support | |
Improved access | Assists with triage and rapid access to specialist services for patients |
The service was inviting to use as staff were accommodating, appointments were easy to access, and communication was enhanced | |
Improved access to professional support, enhanced networking, and broadened skill set for rural clinicians which improved access to services for patients | |
Technological and equipment challenges | Reduced network connectivity in rural areas and poor platform performance |
Equipment unreliable or unsuitable | |
Lack of service communication to rural health professionals | Detail of the service’s existence, equipment required, and training |
Consult processes and making appointments | |
Funding arrangements |
Research context
Theme 1: Patients have reduced travel burden
Unfortunately, one of the barriers with this patient is transport. So he already has a previous amputation in the other leg and there is no way to transport him to the clinic. (Participant 6).A lot of people would prefer to stay on Country if they can be closer to home, they're probably going to take up the service a lot more. (Participant 7)
I had a gentleman that his wife's going through cancer treatment, so she can't travel So, for her to be able to be a part of it, it's beneficial for their whole family really. (Participant 6)
I think definitely the lack of having to drive down, the lack of that time for patients is a massive plus. And, I've probably had a couple where the way I've explained it has been like, "Okay, I'll agree to do the telehealth," versus, "I don't want to go see a specialist. I don't want to go to Adelaide." Whereas then giving them that option, it's kind of been like, "Oh, okay. I actually will take their advice and their input." (Participant 5)
I think it's a much more streamlined process, … it means the patient knows a bit more about what their prognosis might be or what the next steps are or whether they need debridement or amputation or antibiotics or monitoring or lots of dressings. All that can be done without them necessarily having to be physically seen down there in an urgent way … I think it actually helps them [the patient] to probably understand why they might need to do that [go to the metropolitan hospital]. And the timeframe allows them to prepare, live with family, and for us to get our resources together, to help them to get to [the metropolitan hospital], rather than it being more of a crisis situation and a bit more of a rush or a hospital transfer. So, I think it does improve engagement and it allows it to be done more as an outpatient than an inpatient. (Participant 9)
The patient will nod along and be like, "Yep, yep. I understand that," and then afterwards, if I go, "Oh, so that all makes sense?" then they're like, "No." And then I do have to explain it. (Participant 5)
Theme 2: Patients have increased psychosocial support
She being told that it's different to that and that we're all working closer together and that there is that open line of communication that, I think knowing that she has cultural and emotional and mental health aspects of trust in our service, knowing that we were going to be involved in that and be able to advocate for her and having our Aboriginal Health Practitioner in there with her, I think she found that very, very helpful. I think she found a lot less confronting and a lot of safer environment which means she felt more able to engage with that too. (Participant 13)They're already going to their health services [ACCHO’s] anyhow for a whole range of reasons. And it's close access, they know the people, it's comfortable, it's safe ... And I think they felt more comfortable. (Metropolitan TFS staff)
The patient can talk, but I find [it] comes with the health literacy of the patients, we act as an intermediary anyway. So sometimes the patients need that clinician interface locally to assist what's been discussed on the telehealth. (Participant 9)
More of the social and emotional well-being stuff, is the role that I play with it, and not so much, very little clinical stuff … There's no point telling them what they need to do clinically, without addressing the social and emotional well-being side of things. Because if they've got other stuff going on, whatever it is … Yeah, nowhere to sleep, no food to eat. You're not going to care about your foot, especially if you can't feel it … until you've sorted out all the other stuff. A lot of the time people are in survival mode almost, so they do require a lot of extra support. (Metropolitan TSF staff)
The patient talks a lot more in telehealth than in outpatient clinics. They ask a lot of questions. They're really involved a lot of the time, and want to know more information, and often share more information about themselves as well. (Metropolitan TFS staff)
The foot clinics, they are quite crazy, and you've got lots of people jumping in and looking at you, and not really having the time, as much as people would love to, but to really talk and get to know the person, and understand what's going on. (Metropolitan TSF staff)
Because we made a point of seeing every patient that gets the high-risk stuff … And the ones that we haven't met, we've been able to have a yarn with, and get to know them, and feel comfortable with each other. And they feel more safe being there. (Metropolitan TFS staff)
… I think [the AHP] has taught me and made me very much aware of the mistrust that's in the [large metropolitan hospital] people don't trust you straight away. They are very, you know, you're a white face, you're in the [large metropolitan hospital], you can feel that they don't want to tell you what's going on. They don't want to listen to what you say. They don't want to engage. (Metropolitan TFS staff)
Theme 3: Improved access
Assists with triage and rapid access to specialist services for patients
Trying to escalate a patient then [before the TFS was established] was quite difficult. While now with telehealth, their telehealth is acting as that escalation and support mechanism. (Participant 4)
I think it's made access to high-risk foot clinics much more streamlined and easier to be honest. Because it means that certainly the tertiary centres can get a quicker access to that patient. And, I must say, [the metropolitan hospital] has been very good at facilitating our access to high-risk podiatrist services and the vascular and orthopaedics … and then we can make a decision at that first telehealth as to the urgency. (Participant 9)
But having that input of the people higher above us, definitely... That is the reason why this patient possibly isn't going to lose his foot. (Participant 13)
Telehealth, I think it's an amazing solution to try and get that increase in equitable healthcare across the board for especially our rural consumers … I think in terms of closing that gap, it's definitely helped. (Participant 4)
Because the biggest issue we've had here is, obviously the [metropolitan hospital] is having capacity issues at the moment, so we've got patients that are inpatients, that are really poorly, but can't be transferred and have been offered outpatient appointments. And for someone that's bedbound it just doesn't seem fair on the health system and on the patient to cover the cost of an ambulance transport down to [the metropolitan town]. And then them having to sit in the transport only for an outpatient appointment and then to come back… So that's been really good. Just being able to be like, “That’s fine, it can wait'' or, ''No, they need to come now.'' (Participant 1)
We've still got those barriers ... We don't do total contact casting. So you can get that podiatry input but, then the actual hands-on stuff was stuck. (Participant 2)
The service was inviting to use as staff were accommodating, appointments were easy to access, and communication was enhanced
if in doubt, I can basically just call the on-call phone and just say, "Look, I'm concerned about this job on telehealth," or whatever, and have a look. (Participant 5)
[The podiatrist] was awesome. She just owned it. I might add, it was at 2:30 on Thursday before Easter and she was going to be leaving in an hour for Easter. She was switched on. She got it all done. (Participant 10)
[I] desperately think that more services should be providing the ability of this kind of care because it's the ability for clients to have clinic staff be present with them so that everyone knows what's going on and the communication structure that they've had. … Hospital specialists don’t always send us reports, so this is better. And getting those pretty much straight away is fantastic because it means that we're all on the same page. (Participant 12)
It also takes away from the need to actually then communicate via letter or via an email afterwards. (Participant 11)
Improved access to professional support, enhanced networking, and broadened skill set for rural clinicians which improved access to services for patients
It was good just to have input from another hospital … it can be quite isolating. And then for us, it's just connections with other people, experts that know what they're doing. (Participant 10)
Put a vascular surgeon's name and face together as well … I guess it kind of makes things a bit more comfortable, I think, and a bit less formal too. (Participant 12)
It was good to have that support too, from the high-risk foot services to make sure that our current treatment plan, we're on the right track with how we were managing things for the client. (Participant 11)I think that they're [the TFS team] absolutely wonderful. And even just having another set of eyes, they tell you like, ''Oh try this.'' And then you're like, ''Oh yeah, I didn't think of that.'' (Participant 1)
I feel like I can ask her a clinical question, not second-guessing what you're saying, but like, ''I just wonder what your reasoning was behind that''… So being able to learn someone else's clinical reasoning has been good. (Participant 1)
Sometimes just having that metro voice really helps getting the patient to adhere to their offloading plan or to take their antibiotics properly or look after their sugars or whatever it might be. (Participant 4)
If vascular link in, yeah, there's definitely stuff to be learned from some of those conversations that they have with the client. (Participant 14)
It would be nice to have the vascular there all the time. (Participant 5)You don't often see vascular, it's kind of just with podiatry on the other end, … But when you're wanting something more and that's not there on that particular day, that can then be a bit of a barrier into getting the right care because it's kind of just doubling up on the service that the client's already getting. (Participant 14)
I think the users on the other end, they've worked in country, or they've got a bit wider understanding about if we're reaching out for assistance, we really need that assistance now. And they're quite responsive, which is good. But my own personal experience is it has improved collaboration between the two. (Participant 4)
As it went on, the relationship got stronger. And trust, telehealth is here to work together to make sure the patient gets the care that they need. (Metropolitan TFS staff)
Before TFS the Aboriginal hub did not know podiatry existed at [the metropolitan hospital], now we all know each other by name. We're getting actual referrals from the hub. (MetropolitanTFS staff)
The Aboriginal community-controlled sites don't talk to the LHNs a lot of the time. … Telehealth has been a way to bring them together in some areas. (Metropolitan TFS staff)
Theme 4: Technological and equipment challenges
Reduced network connectivity in rural areas and poor platform performance
We don't have Wi-Fi access. So it's trying to have a big, long internet cord connected through or where, if we're out in the region, the service isn't that great. (Participant 14)
Healthdirect [is] failing as a platform. And you end up having to do the rest of the consult via FaceTime or just on a telephone call. (Participant 4)
Unsuitable or unreliable equipment
The camera on the computer decided not to work... so unfortunately we ended up just talking on the phone. (Participant 7)In [a rural town], we weren't able to get a laptop. We would borrow one of the iPads from telerehab. (Participant 4)I find that telehealth's a little challenging in terms of being able to show you the patient's foot with a camera on a fixed computer. (Participant 9)
I guess if it’s a poor-quality image of the wound, the podiatrist on the other end can’t even really see… if you’ve got that Logitech camera, it’s good. But if not, if you’re trying to do it off your phone or your tablet it’s not as effective, not as clear (Participant 8).
Theme 5: Lack of service communication to rural health professionals
The services existence, equipment required, and training
I think if there's better awareness that this resource is available for us to then have it as a resource… Because I actually didn't know this existed. (Participant 13)
When the service was set up, they kind of just said, this is what we're doing, but didn't really give us much of an idea of what we would need. (Participant 14)
It took me a little while to actually get set up … So I had to do a bit of phone calls and emails and running around to try and find out how I actually start the whole process. (Participant 11)
Processes for consultations and making appointments
Having something in writing… like a health pathways kind of document that says you'd like these particular tests before you see a patient… these particular images at these particular angles, they're always kind of helpful things for our end… And also who you would like to be on the telehealth that you'd find helpful. (Participant 9)
It's sometimes unclear when booking the telehealth as to whose responsibility, who does what, … It makes sense for the local team to call and book the patient in because they know the directions, how to get there, where the car park is and all those sorts of things. So again, probably just a bit of clarity from metro to country about who does what in terms of booking that appointment would sometimes be a bit better. (Participant 4)
They're [the metropolitan staff] probably not very flexible with time… So, that means that we have to move other people around. Or, another thing, probably because they're metro that we don't consider some of the regional aspects. So they might be like, "Oh, I want to see so and so at Friday, at 10 o'clock," but they're not located in [the major regional town]. They might be in [a small rural town] four hours away. So, it's probably like they almost should be revolving around when we are seeing the client. (Participant 8)It's probably more difficult from our end just because our appointments are often booked up. We don't have necessarily time kept aside each day for if these requests come through for a telehealth consult. (Participant 14)
Funding arrangements
If it's something that they want to continue on long term, it's probably more looking at funding, how it's getting funded. Who's getting the funding. Because obviously it's great to have their numbers grow, but if our FTE's not growing out in the region, we don't then have the capacity to always be providing those services and that sort of thing. (Participant 14)
“They have to pay for their offloading, all of that. And then they go down to the [metropolitan hospital] and they don't have to do that. And then the patient gets, ''Well, who should I be going with?'' And that kind of thing. (Participant 1)
Depending on what episode type we see the patient under depends on how much they're charged for that appointment. And so if we're seeing someone under a Commonwealth Home Support Package episode, they're charged in the number of minutes that they're in the chair for, while if we're seeing someone under community health, it's just per presentation. And then sometimes we see them under an outpatient episode where it's free.So again, different consumers are having to contribute different amounts depending on where they are and what episode type they fall under too. So I guess in terms of that continuity, it's not there from a regional LHN point of view because we're now six regional LHNs. And they all interpret the rules around telehealth a little bit differently. And all do it differently. (Participant 4)
I think that's [telehealth] probably the best thing that's come out of COVID, that tertiary centres and private specialists have finally embraced telehealth. (Participant 9)