Increasing the use of video telehealth in residential aged care homes: A mixed-methods evaluation of a practical telehealth training program to support telehealth implementation

Setting

The Brisbane North Primary Health Network (BNPHN) is a federal initiative connecting healthcare providers and services to improve primary care for patients. ¹² It services over one million residents covering 4100 km² of mixed metropolitan, regional, and rural areas. ¹²

Preliminary work

BNPHN commissioned the Telehealth Readiness Assessment Tool and Business Process Training Toolkit ¹³ for the project (see assessment tools, training materials and evaluation measures). Funding was provided to RACHs to assist with purchasing equipment and telehealth business process training.

Pre-training online consultation

A list of 54 RACHs who had received funding and procured their telehealth equipment was shared with The University of Queensland's Centre of Online Health team, who are experts in the use and implementation of telehealth. An initial online meeting with each RACH used the business process checklist (see assessment tools) to assess their current telehealth activity, knowledge and processes. The information was also used to customise training materials. Virtual clinics for each RACH were set up on the Healthdirect (HD) Video Call platform, a secure, government-funded videoconferencing software designed for clinician-to-patient consultations available to all Australian RACHs at no cost. ¹⁴

On-site telehealth training

On-site training sessions included presentations and discussions on telehealth benefits, workflows, best practices and hands-on simulation video calls. Clinic administrators learned to customise their virtual clinic. Telehealth policies and procedures were discussed with Quality Improvement Leads. Each site received a toolkit for ongoing staff training containing sample policies and procedures. Ethical exemption was obtained from The University of Queensland's Human Research Ethics Committee (#2023/HE002435).

Assessment tools, training materials and evaluation measures

Various assessment tools, training materials, and evaluation measures were used pre and post the telehealth training.

Analysis

Data sets were independently collected and analysed. Descriptive analyses were conducted for the business process checklists, pre- and post-training and follow-up surveys. A two-sample independent t-test was used for pre-post training data with statistical significance set at 0.005. Consultant diaries and qualitative follow-up data were analysed using inductive coding to identify themes and patterns, that were categorised into broader themes. Data sets were compared for deeper insights. ¹⁵

Business process checklist

Forty-two RACHs participated in online meetings. Organisations with multiple RACHs using the same processes were combined into one meeting, resulting in 34 completed checklists. Telehealth (phone and video) was used in 50% of RACHs, mainly via phone. GPs and hospital/emergency department in-reach services were the most common telehealth users. In 19% (n = 6) of RACHs, GPs did not use telehealth, and 9% (n = 3) reported that GPs were unwilling to use video for consultations. One RACH had successfully deployed telehealth with consultations taking place with GPs, wound specialists and allied health practitioners.

Training evaluation

Forty-one RACHs received onsite training with 37 (90%) completing pre and post evaluation forms. Four RACHs requested webinars to complement their organisation's telehealth training program. A total of 377 participants took part in training, the majority of which were nurses (88%, n = 331). Table 2 details the participant roles.

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Table 2.

Participant role (n = 377)

RACH staff role*	N (%)
Nursing	331 (88)
Administrators	21 (6)
Personal Care/health care workers	18 (5)
Allied Health	4 (1)
Other	3 (0.8)

*Staff could select more than one discipline

The independent t-test demonstrated that self-rated scores post training had resulted in statistically significant higher scores in telehealth knowledge and skills (M = 77.34, SD = 19.07) and confidence (M = 79.04, SD = 19.50) compared to pre-training telehealth knowledge and skills scores (M = 41.01, SD = 29.77, t(310)=–13.86, p < 0.001, Cohen's d = –1.485), and confidence scores (M = 46.78, SD = 30.61, t(305)=–11.96, p < 0.001, Cohen's d = –1.247) (Table 3).

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Table 3.

Pre and post self-rated scores for telehealth knowledge, skills and confidence on a scale from 0-100 (n = 365).

	Pre-Mean (SD)[Pre-surveys completed]		Post-Mean (SD)[Post-surveys completed]		P-value
Telehealth knowledge and skills	41.01 (29.77) [184]		77.34 (19.07) [181]		<0.0001
Confidence	46.78 (30.61) [183]		79.04 (19.50) [182]		<0.0001

Statement	Pre n (%) agreement [Total responses]	Pre-Mean (SD) [CI]	Post n (%) agreement[Total responses]	Post-Mean (SD) [CI]	P-value
I think telehealth will be useful for our residents.	149 (81) [184]	4.02 (1.09) [3.86, 4.18]	164 (90) [182]	4.32 (1.09) [4.16, 4.48]	0.0098
I understand the benefits of telehealth for my residents.	161 (88) [183]	4.22 (0.78) [4.10, 4.33]	178 (98) [182]	4.60 (0.62) [4.51, 4.69]	<0.0001
I know how to set up a videoconference call.	94 (51) [183]	3.32 (1.15) [3.15, 3.49]	170 (93) [182]	4.44 (0.68) [4.34, 4.54]	<0.0001
Telehealth will help our service gain access to more timely care for our residents.	164 (86) [184]	4.23 (0.86) [4.10, 4.35]	176 (97) [182]	4.54 (0.67) [4.44, 4.64]	0.0001
I intend to help promote telehealth in my service.	159 (86) [184]	4.20 (0.85) [4.07, 4.32]	172 (95) [182]	4.51 (0.68) [4.41, 4.61]	0.0001

Consultant diaries

Major barriers reported for implementing telehealth included transitioning external health providers from phone to video consultations and poor internet connectivity in RACHs’ ‘black spots’ or the lack of equipment. Overwhelmingly, RACH staff were motivated to use telehealth to enable family members to attend consultations, reduce travel burden, avoid hospital transfers and access after-hours care. Further challenges and motivators identified by consultants are listed in Table 4.

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Table 4.

Qualitative data from consultant diaries.

Theme	Issues
Challenges for implementation	Transitioning external providers from phone to video consultations due to lack of training/motivation or resistance to change
	Equipment or Wi-Fi difficulties
	External providers visit inperson reducing the need for telehealth
	Residents' rooms are too small to use the computer on wheels
	RACH staff lack of training/ongoing support
	Staff shortages/turnover
	Time to implement
	Workflow difficulties
	“Buy-in” from senior staff
	Internal barrier e.g. IT policies
	Finding health professionals who will use video telehealth
Motivators for implementation	Enabling family members to attend consultations
	Reducing travel burden on residents, health professionals (staff and external providers) and family members to attend in person appointments
	Accessing GPs (including After Hours), specialist services or urgent care
	Accessing interpreter services
	Sharing information from another clinical system e.g. medication lists
	Avoiding hospital transfers
	Providing residents’ choice
	Senior staff support

Follow up survey

Thirty-five sites (85%) could be reached for a follow-up survey on telehealth activity, averaging 109 days post training (range 15 days to 7 months). Respondents were mostly the facility or clinical services manager (49%, n = 17) with other roles including the nurse manager, director of care, residential care manager and care coordinator.

Staff confidence

During the initial Telehealth Readiness Assessment, respondents were asked about staff confidence in using telehealth. Two RACHs (6%) reported that >80% of staff were confident, whereas post-training this had increased to fourteen RACHs (40%) (Table 5).

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Table 5.

Staff confidence in using telehealth.

Overall proportion of staff confident using telehealth	Initial telehealth readiness assessment data (n=35)	Follow-up survey post-training (n=35)
0-40%	19 (54%)	9 (26%)
41-79%	14 (40%)	12 (34%)
>80%	2 (6%)	14 (40%)

Other aspects of the telehealth business process support

The final section of the survey was about digital health processes (Table 6). Many RACHs (68%, n = 24) had not initiated setting up their access to My Health Record. They reported that this was undertaken at an organisational level, rather than by individual RACHs. Two RACHs found the sign-up process challenging and were unable to connect but were very keen to have access.

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Table 6.

Proportion of RACHs that have put in place certain digital health processes (N = 35).

Question	n (%) of RACHs that responded “Yes”
Were the telehealth business practices shared with you during training helpful?	33 (94%)
Have the telehealth business practices been put into practice?	22 (63%)
Has your facility/organisation now signed up for My Health Record?	6 (17%)
Do you have access to an Electronic Medication Management System?	26 (74%)

Motivation for using telehealth

The training program was well-received, with participants appreciating the practical components, such as simulated video calls. This hands-on approach was crucial in building confidence and competence among staff. The motivation to use telehealth was driven by the need to access specialised services and reduce the travel burden for residents and health providers. ¹⁰ These findings align with previous research highlighting the benefits of telehealth, improving access to care and reducing logistical challenges.^10,11,16 A novel finding from our study was staff wanting to use telehealth so family members could attend consultations with residents while external health providers were visiting the RACH as well as with health providers participating in a telehealth consultation.

Family members play an important role in overseeing the care of their loved one living in a RACH, including seeking information about care, acting as representatives, and sharing personal knowledge about residents to care providers. ¹⁷ The importance of telehealth in an RACH is underscored, as it can mitigate the many barriers to transporting residents to outside appointments and reduce stress on family members. Residents are often dependent on family members taking them to outside appointments. However, logistical issues such as work, family commitments, living far away or illness can prevent and limit their ability to accompany residents or be present when consultations take place. RACHs’ policies on staff accompanying residents to consultations vary with some requiring residents to pay for staff accompanying them to appointments, whilst others do not have sufficient staffing levels to offer this service.

RACH staff are responsible for providing information about the treatment and care of residents to their family members. Our study identified staff greatly valued telehealth as a mechanism that would improve information flow between health providers and family members by enabling family members to attend consultations and ask questions directly to the prescribing clinician. This would reduce staff time spent on mediating this information and potentially provide a more accurate direct transfer of information from the external health professional to the family member. In a setting where staff shortages and retention are a major problem that impacts on patient care, developing strategies to improve efficient use of staffing time is required.

Engaging with external health service by telehealth

Follow-up data indicated an increase in the use of video telehealth with a external clinician-led model, where the RACH uses the external health service providers’ link to access a call. Although most RACHs are not sending the call links, the training has enabled them to participate with services using video telehealth. A RACH-led model of telehealth, where the RACH sends the link, assumes that RACH staff have influence on external health providers’ decisions in using video telehealth. Clinical managers reported the opportunity to increase video telehealth activity, but a major barrier, is external providers’ resistance to transitioning to video telehealth. The hierarchical nature of health professionals, in which doctors and consultants were observed to be the decision-makers, means that RACH staff have limited ability to influence these health professionals’ decisions. Training targeted for these RACH health providers is required to improve their understanding and skills in delivering care by telehealth as well as identifying successful implementation strategies that will increase use.

The iterative nature of telehealth implementation

This study also highlights the iterative nature of telehealth implementation. Supplying equipment and training alone is not enough to increase telehealth adoption. Successful telehealth implementation requires leadership at an organisation and site level. ¹⁸ Working at an organisational level was out of scope for this project. However, each site did identify telehealth champions who will require ongoing support from the PHNs if telehealth use is to be scaled across their footprint. The study also highlights the unique context of RACHs and their diversity in readiness and capability for training and telehealth implementation. Tailored training to each RACHs’ needs is required if we are to change their traditional clinician-led model to a more proactive RACH led one. Future work needs to focus on change management and tailored support specific to the local RACH needs and challenges. RACHs also require further help to access residents’ My Health Record.

Strengths & limitations

A key strength of this project was the inclusion of a diverse range of RACHs in the training and evaluation process. RACHs varied in size and geographical location, representing metropolitan, regional and rural areas. However, several limitations should be acknowledged. First, participation was voluntary meaning that RACHs self-selected into the study, which may introduce selection bias. Second, because the pre- and post-training evaluations were completed on the same day, we were unable to determine if the observed improvements in competency were sustained over time. Similarly, while initial evaluations showed good adoption of telehealth, a longer-term assessment is needed to understand its sustained use. The RACHs involved in the training may have had a more positive attitude towards telehealth, as a commitment was required to purchase equipment and engage in the training to receive funding from the BNPHN.