Understanding the Experience of Geriatric Care Professionals in Using Telemedicine to Care for Older Patients in Response to the COVID-19 Pandemic: Mixed Methods Study

Background Geriatric care professionals were forced to rapidly adopt the use of telemedicine technologies to ensure the continuity of care for their older patients in response to the COVID-19 pandemic. However, there is little current literature that describes how telemedicine technologies can best be used to meet the needs of geriatric care professionals in providing care to frail older patients, their caregivers, and their families. Objective This study aims to identify the benefits and challenges geriatric care professionals face when using telemedicine technologies with frail older patients, their caregivers, and their families and how to maximize the benefits of this method of providing care. Methods This was a mixed methods study that recruited geriatric care professionals to complete an online survey regarding their personal demographics and experiences with using telemedicine technologies and participate in a semistructured interview. Interview responses were analyzed using the Consolidated Framework for Implementation Research (CFIR). Results Quantitative and qualitative data were obtained from 30 practicing geriatric care professionals (22, 73%, geriatricians, 5, 17%, geriatric psychiatrists, and 3, 10%, geriatric nurse practitioners) recruited from across the Greater Toronto Area. Analysis of interview data identified 5 CFIR contextual barriers (complexity, design quality and packaging, patient needs and resources, readiness for implementation, and culture) and 13 CFIR contextual facilitators (relative advantage, adaptability, tension for change, available resources, access to knowledge, networks and communications, compatibility, knowledge and beliefs, self-efficacy, champions, external agents, executing, and reflecting and evaluating). The CFIR concept of external policy and incentives was found to be a neutral construct. Conclusions This is the first known study to use the CFIR to develop a comprehensive narrative to characterize the experiences of Ontario geriatric care professionals using telemedicine technologies in providing care. Overall, telemedicine can significantly enable most of the geriatric care that is traditionally provided in person but is less useful in providing specific aspects of geriatric care to frail older patients, their caregivers, and their families.


Introduction
Canada's older population remains at the greatest risk of dying from COVID-19, caused by the novel SARS-COV-2 virus [1]. Yet, the same public health measures being imposed to protect this population have also posed an ongoing challenge for older persons in accessing in-person care in a timely manner since the beginning of the COVID-19 pandemic. In response, the Government of Ontario's health care system, like several others, rapidly supported the early and widespread adoption and use of its existing and other telemedicine technologies, including the telephone or popular videoconferencing platforms, such as Zoom and Skype, for health care professionals to deliver safe and effective remote or virtual care throughout the COVID-19 pandemic [2].
For older persons, previously noted beneficial outcomes of Ontario's telemedicine services have included a decrease in wait times for access to specialists [3] and a significant reduction in emergency department (ED) admissions [4]. However, until the beginning of the COVID-19 pandemic, there remained major challenges that hindered the widespread adoption of telemedicine technologies by health care professionals across Ontario. For example, a main barrier was that prior to the COVID-19 pandemic, Ontario physicians could only be reimbursed for providing telemedicine services if they and their patients were able to use the Government of Ontario's Ontario Telemedicine Network (OTN) secure videoconferencing technologies to conduct patient visits [5]. Telephone-based consultations or follow-up were not reimbursable in general for Ontario physicians, except for geriatricians when providing caregiver advice and support to one of their established patients. Furthermore, another main barrier was that acquiring the required communication technologies to enable secure videoconferencing via telemedicine could be expensive for both patients, their caregivers and families, health care professionals, and their organizations, although this was becoming less of an issue in recent years with the greater availability of secure web-based communication technologies using standard computer equipment. Indeed, many older persons, their caregivers, and their families might also not be able to access the technology needed to use telemedicine services [6]. In addition, many older persons with cognitive and sensory impairments need to rely on health care professionals or unpaid caregivers and family members to assist with or manage the technology [6]. This is a particular concern for those who are homebound or live in isolation, as they may not readily have access to the level of health care professionals or caregiver support necessary for accessing telemedicine technology-enabled supports [7]. Nevertheless, evaluations of Ontario telemedicine programs, prior to the COVID-19 pandemic, have demonstrated high satisfaction among older patient users [3,6,[8][9][10][11].
Despite positive reported patient outcomes, there remain gaps in the current literature on whether the use of telemedicine technologies can adequately meet the needs of Ontario geriatric care professionals to facilitate the delivery of the range of care they provide. Many observed findings from previous evaluations of Ontario telemedicine programs have reflected the needs of patients and program stakeholders specific to individual conditions, such as telehomecare for older patients with chronic obstructive pulmonary disease (COPD) and heart failure [6], or more specific geographical needs, such as the provision of geriatric medicine and psychiatry outreach clinics to rural and remote communities [9]. Meanwhile, the complexities that geriatric care professionals in Ontario typically manage using a holistic in-person approach that assesses the complex and often interrelated health and social issues experienced by their older patients have not been addressed through prior studies examining the use of telemedicine technologies.
Another issue is that many of the existing Ontario telemedicine programs have tended to target older persons who were more able-bodied, and have often excluded the more vulnerable, older persons with complex conditions [6,12,13]. In particular, health care professionals did not see the benefit of using telemedicine technologies with older persons with physical and cognitive impairments, as they were concerned that this older subgroup of patients could not keep up with the unique demands a remote consultation requires [6,14,15]. However, the exclusion of this subgroup in prior studies has only served to pose a greater challenge for geriatric care professionals in assessing their ability to transition to using telemedicine, particularly with their older patients with complex conditions [16].
At the outset of the COVID-19 pandemic, Ontario geriatric care professionals could not be as selective with their older patients regarding how best to care for them under existing public health measures, including when lockdowns and other restricted visiting orders were enacted and there was a general fear of the possible consequences that could befall older patients with complex conditions seeking nonemergent health care services. Ironically, all these factors could further promote physical and social isolation that increase the risk of worsening functional decline and mental health issues that could actually result in more ED visits and acute hospital admissions [15,17].
Existing telemedicine research also has not addressed how best to facilitate and support the level of care that Ontario geriatric care professionals aim to provide. The current literature indicates that virtual care visits require various ongoing background coordination supports, such as patient data management, patient care monitoring, and facilitation of communications between health care staff involved in care planning [6,15,18]. In addition, telemedicine technologies have often been associated with a limited ability to perform a physical exam [19,20] and a difficulty in observing verbal and nonverbal cues that could impact establishing reliable diagnoses [19,21]. Therefore, the consulting health care professional has often needed to rely on a health care facilitator, whenever possible, who would be on the premises with the patient (eg, a local physician or nurse), as their support, which has been seen as crucial for an effective remote visit [15]. However, in the current COVID-19 pandemic paradigm, consulting health care professionals have also had to serve as facilitators, managing all aspects of the telemedicine visit unless there was a family member, caregiver, or health care professional present to assist with a visit. Therefore, this study aims to determine the benefits and challenges Ontario geriatric care professionals have faced in using telemedicine technologies to provide routine consultations and follow-up care to their older patients with complex needs,  their families, and their caregivers, as well as the conditions  under which this method proves to be or not be an effective way  to provide care. Moreover, identifying frontline benefits and  challenges would also provide new learning opportunities for  geriatric care professionals across different health care settings and regions in the use of telemedicine technologies [22], which is still a novel approach in the practice of geriatric medicine [13].

Study Design
This was a mixed methods study that included the following: (1) a survey that inquired about the demographic information of participating geriatric care professionals, their experience, and current satisfaction with the use of telemedicine technologies to provide care to their older patients and their caregivers and (2) a semistructured interview that reflected the objective of the study but also allowed participants to freely express their additional perspectives about the use of telemedicine technologies to provide care. Please see the Multimedia Appendix 1 for the semistructured interview guide.
The Consolidated Framework for Implementation Research (CFIR) was used to assess the barriers and facilitators toward providing care with telemedicine technologies identified in the semistructured interviews. The CFIR was identified as an appropriate methodological framework for providing a comprehensive evaluation of the barriers and facilitators in the implementation of health care technologies across multiple contexts [16,23,24]. The CFIR consists of 5 domains: intervention characteristics, outer setting, inner setting, individual characteristics, and the process of implementation [24]. Within each domain, there are various constructs that guide users to identify barriers and facilitators that impact implementation [24].

Participants
This study targeted geriatric care professionals who use telemedicine technologies with older patients, their caregivers, and their family members in an outpatient setting to provide routine consultations and follow-up care. The geriatric care professionals were recruited through the Divisions of Geriatric Medicine and Geriatric Psychiatry at the University of Toronto, Canada, and the local Regional Geriatric Program of Toronto between January and April 2021.
A total of 30 geriatric care professionals representing the fields of geriatric medicine, geriatric psychiatry, and geriatric nursing were invited to the survey and participated in a semistructured interview. These geriatric care professionals work in geriatric outpatient clinics that often do not use allied health care workers.

Ethical Considerations
Participants provided either written informed consent or audio-recorded oral consent. The study protocol was approved by the Toronto Metropolitan University Research Ethics Board (#2020-513-1).

Data Analysis
The Statistical Package for the Social Sciences (SPSS; IBM Corporation) was used to analyze the survey responses and determine participant characteristics. A deductive thematic approach to analysis was used to analyze the semistructured interviews. Authors WC and AF independently coded the transcripts using the codebook based on the CFIR constructs [24], which was modified to reflect the local geriatric care professionals' practice. NVivo (March 2020 release; QSR International) was used to facilitate the coding process. Following a codebook helped to minimize coding differences, and weekly discussions were held to resolve coding differences.

Participant Characteristics
Of the 30 participants, 22 (73%) were geriatric medicine specialists or geriatricians, 5 (17%) were geriatric psychiatrists, and 3 (10%) were geriatric nurse practitioners. In addition, 28 (93%) participants completed both the survey and the semistructured interview. The survey results of 2 (7%) participants were not collected due to personal choice or technical difficulties. Tables 1 and 2 provide a detailed overview of the participant characteristics and satisfaction with telemedicine use, respectively, from the 28 completed surveys.

Relative Advantage
Using telemedicine technologies increased access to older patients who were homebound, were reluctant to come in due to COVID-19, or lived in remote areas. Many geriatric care professionals perceived that virtual care visits allowed older patients the convenience to receive care in their own homes without the hassle of traveling. Older patients who were previously "no shows" for their appointments were also more likely to be reached. Virtual care visits also provided greater schedule flexibility for geriatric care professionals to accommodate the schedules of their older patients, their caregivers, and their families more easily.

Design Quality and Packaging
Geriatric care professionals used a variety of videoconferencing platforms and the telephone to conduct virtual care. However, many statements revealed that connectivity issues were often still a barrier for both geriatric care professionals and their older patients in using videoconferencing platforms.
Regarding the types of telemedicine technologies, many statements indicated a preference for videoconferencing over telephone communications as the geriatric care professionals could see their older patients and their living environments. Many statements also revealed that geriatric care professionals would like videoconferencing platforms to have the ability to facilitate more interactions with their older patients. However, some indicated their older patients preferred telephone communications. In addition, some found that their older patients with hearing impairments could hear better since there was the ability to adjust volume. Few geriatric care professionals indicated they used email communications or text messages with their older patients.

External Policy and Incentives
Confidentiality and the security of networks were not a major concern for geriatric care professionals. Several geriatric care professionals questioned the future payment model and discussed the need for more guidance on the billing process for virtual visits.

Patient Needs and Resources
Many statements revealed that telemedicine visits are more effective if the patient has their own monitoring devices that could provide clinical health information, such as vital signs, and a caregiver, family member, or health professional to assist the patient during the visit. However, many expressed concerns about the support and available resources for their older patients to use telemedicine. Several also expressed concerns about the health and technology literacy of their older patients and caregivers.

Networks and Communications
Many statements revealed geriatric care professionals relied on quality collateral information (eg, patient medical history) derived from their older patients' caregivers, families, referring physicians, local team members, and electronic medical record (EMR) systems.

Implementation Climate
This construct was broken into two subconstructs: tension for change and compatibility.

Tension for Change
The rapid implementation of telemedicine technologies by geriatric care professionals across Ontario was due to the COVID-19 pandemic.

Readiness for Implementation
Many geriatric care professionals found the transition to virtual care visits was unexpected and sudden. However, a few statements also revealed that those who had previous experience with telemedicine use found the transition to be smooth. This construct was also broken down into two subconstructs: available resources and access to knowledge.

Access to Knowledge
Several geriatric care professionals indicated they could adopt the training on telemedicine into their clinical practice, but there was still a learning curve.

Knowledge and Beliefs About the Intervention
Many geriatric care professionals perceived that virtual care visits will be incorporated into their clinical practice in the future due to their benefits in reaching their older patients.

Self-Efficacy
Many geriatric care professionals were confident in using telemedicine technologies to meet the care needs of their older patients with complex conditions, their caregivers, and their families. However, some were still apprehensive about their ability to conduct care virtually.

Engaging
This construct was broken down into two subconstructs: champions and external change agents.

Champions and External Change Agents
Several statements indicated that having a champion in the team or an external role model helped facilitate the implementation of telemedicine technologies.
We, as a clinic, were very lucky to have a clinician, which was just on top of all of these new changes, and [were] able to switch from seeing patients in person to telemedicine. [Geriatric care professional 2]

Executing
Several geriatric care professionals found that they were more efficient with time during the virtual care visit, but it did not increase their patient capacity. Some statements revealed that there was additional follow-up work required with telemedicine use, especially if the older patient needed to be followed up in person.

Reflecting and Evaluating
Several statements revealed that geriatric care professionals would frequently reconvene with their clinical teams or peers to evaluate their experiences with telemedicine use.
And we would also meet with the RGP, which is the Regional Geriatric Program.

Principal Findings
In this study, the CFIR was used to develop a comprehensive narrative of the current experiences of geriatric care professionals in routinely using telemedicine technologies in Ontario in the light of the COVID-19 pandemic. Although 5 barriers and 1 neutral construct were identified, so too were 13 facilitators.
This mixed methods study adds to the growing literature on the use of telemedicine to provide geriatric care before and during the COVID-19 pandemic, and we found similar findings to other recent studies that also explored geriatric care professional experiences with the use of telemedicine during the COVID-19 pandemic [22,[25][26][27][28][29]. The ubiquitous transition to using telemedicine in the provision of geriatric care was uniformly driven by the COVID-19 pandemic. Geriatric care professionals faced an initial learning curve as they learned to incorporate telemedicine technologies into their routine clinical practices. However, for geriatric psychiatrists specifically, there was a more seamless transition to virtual care due to the nature of their clinical practice that has always been more amenable to the use of telemedicine technologies, which differs from geriatricians and geriatric nurse practitioners. For example, the physical examination is usually not necessary to complete a psychiatric assessment [30,31]. Meanwhile, the main challenge for geriatric psychiatrists was using telemedicine technologies with older patients with severe cognitive impairment. In a systematic review on telemedicine and dementia, Sekhon et al [15] had identified that in-person consultations are more appropriate for this subset of older patients with complex conditions.
Our study findings also raised additional unique insights being experienced by Ontario geriatric care professionals. Notably, our study was able to explore the range of strategies adopted by Ontario geriatric care professionals to complete their clinical assessments virtually, whereas other recent studies have largely focused on navigating the technological aspect of telemedicine use to overcome barriers [22,26]. As noted in Adaptability, Ontario geriatric care professionals quickly adopted the use of validated clinical tools that could enable them to virtually conduct their assessments or better prioritize assessment components when certain aspects were hindered by the challenges in using telemedicine technologies. Thus, with regard to improving telemedicine technologies to facilitate the more effective provision of geriatric care, Ontario geriatric care professionals would like videoconferencing platforms to have the ability to facilitate more interactions with their older patients, such as the capability to see how their older patients complete the actual written exercises in the validated clinical tools they use. Observing how their older patients actually complete these exercises, such as drawing a picture or connecting dots, provides important insights for the geriatric care professionals regarding the physical and cognitive abilities of their older patients.
Another notable finding to support overcoming identified barriers was around the role of collateral information derived from caregivers, friends, family members, referring colleagues, and EMR systems. The responses of our study participants illuminated the importance of collateral information, as discussed in the Networks and Communications construct which played a crucial role across the whole implementation process in the virtual delivery of care. However, gathering sufficient collateral information was a complexity for our study participants, while Watt et al [28], in a recent study, had found that the persistent need to collect collateral information is a complexity for virtual care. Nevertheless, collateral information helps provide a comprehensive overview of the patient's medical and social history for geriatric care professionals without needing to see the patient in person to derive this. Furthermore, linkable EMR data were associated with more opportunities for understanding the patient journey through the care continuum [32]. Hence, geriatric care professionals were often still able to make effective clinical decisions virtually for their older patients when given sufficient collateral information that helped compensate for the other factors that can limit the usefulness of telemedicine. Watt et al [28] had also indicated that geriatric care professionals found collateral history to be particularly useful for telephone assessments in which visual assessment was not possible.
Due to the inherent challenges that exist in using telemedicine technologies, the Compatibility construct revealed a consensus from the responses of study participants that the role of telemedicine technology for Ontario geriatric care professionals was more appropriate for follow-up visits. Participants reasoned that follow-up visits do not require as comprehensive assessments as an initial consultation that would likely have components that benefit from an in-person assessment, such as a physical examination or certain cognitive tests. This aligns with findings by Watt et al [28] and studies that have evaluated physicians' experiences in telehealth visits with older patients in the context of US practice [26,29].
Regarding the observed perceptions of patient needs and resources, the responses of this study's participants echoed concerns around the "digital divide," which continues to be a major barrier for older persons to using telemedicine technologies in Ontario [8,25,26,33]. In particular, their responses revealed important necessary aspects for an effective virtual care visit to take place without the assistance of a health care facilitator present with their older patients. Many of our study participants had indicated that their older patients often relied on the presence of a caregiver or a family member to access the communication technology and to manage the virtual care visit. This is also supported in recent studies in which primary care physicians found the assistance of family members and caregivers to be helpful in the facilitation of the telehealth visit for their older patients [22,29]. Additionally, our study found that the visits were even more effective for older patients who had monitoring devices that could provide basic health information, but not all older patients owned these devices. However, the varied level of health and technology literacy of their older patients and their caregivers or family members posed challenges for the ability of geriatric care professionals to collect information for their clinical assessments virtually.
The responses of our study participants suggest that there exist three necessary aspects to achieve an effective virtual care visit for both geriatric care professionals and their older patients: (1) access to the telemedicine visit-enabling technology (smartphones, tablets, computers, or telephone); (2) access to health-monitoring equipment to provide basic health information, such as blood pressure monitors; and (3) appropriate health and technology literacy amongst older patients and their caregivers or family members. Essentially, older patients or their caregiver or family member would need to assume the traditional role of the on-site health care facilitator. The reality, however, is that only a certain portion of older Ontarians have the means and ability to support the effective use of telemedicine services. It is less likely for older persons to use telemedicine technologies if they lack confidence with using related technologies [11,22,26] or to receive virtual care visits via videoconferencing if their caregivers could not be present [34]. Recent studies also indicate that older persons at the lower end of the socioeconomic spectrum are often overlooked as they lack equitable access to the appropriate resources and support to facilitate virtual care visits [25,26,35], and geriatric care professionals have observed worsening of this disparity during the COVID-19 pandemic [25]. This is important to note since a main purpose of telemedicine technologies is to bridge the gap in care accessibility for older persons who live in low-resource settings [36].
Lastly, an important consideration is how evolving policies and incentives could fundamentally change the landscape for providing virtual care visits in Ontario. As discussed in the External Policy and Incentives section, our study's geriatric care professionals raised concerns, including around the ambiguity about future billing processes for the provision of virtual care visits. Although the Government of Ontario quickly implemented temporary billing codes and guidelines to facilitate the provision of virtual care visits at the start of the COVID-19 pandemic [37], the future funding model for virtual care visits in Ontario will largely reflect the recent impact on the use of telemedicine technologies due to the COVID-19 pandemic [2,26]. If Ontario geriatric care professionals continue to embrace the use of virtual care visits, future funding policies will need to determine how to broadly support the appropriate use of telemedicine to provide high-quality geriatric care, while recognizing there still exist socioeconomic barriers to accessing it and trade-offs related to its use [28].

Strengths and Limitations
This is the largest known study pertinent to the real-world experience of geriatric care professionals using a wide range of telemedicine technologies in the light of and during the first year and a half of the COVID-19 pandemic. This study further used the CFIR to provide a comprehensive overview of the various strategies geriatric care professionals have used to overcome the complexities surrounding the provision of outpatient virtual care with older persons, their caregivers, and their families. Another strength is that this study included a wide-ranging age group of geriatric care professionals. In addition, this study primarily focused on the experiences of geriatric care professionals and did not evaluate older patients' and their caregivers' perspectives. Yet, despite the lack of these perspectives, responses across all the constructs were effective in revealing the various practice changes and strategies used to address the diverse needs of older patients with complex conditions in the virtual care setting.
There are several limitations to the study. First, the findings are limited to the experiences of geriatric care professionals in Canada's Greater Toronto Area. In addition, the experience of nonmedical or nursing allied health professionals, who are also integral members of some geriatric care teams, was not included. Nevertheless, the majority of Ontario's geriatric care professionals work in the Greater Toronto Area, with the vast majority being geriatricians, geriatric psychiatrists, and nursing care professionals who were included in this study. In addition, this study's CFIR construct Reflecting and Evaluating indicated that geriatric care professionals are continuously evaluating their own experiences that shape their knowledge and beliefs about the use of telemedicine in their practices. Hence, the findings presented herein should represent a snapshot of the current needs of geriatric care professionals that will likely evolve as we continue to navigate the opportunities to using telemedicine technologies to deliver geriatric care.

Recommendations
Based on the findings of this study, we offer the following four recommendations to support the continued and enhanced use of telemedicine technologies by geriatric care professionals in providing care to older patients, their caregivers, and their families: 1. Continuing training and education for geriatric care professionals in the use of telemedicine technologies is needed: Prior training on telemedicine use had helped facilitate a smoother transition for geriatric care professionals during the rapid transition to predominantly providing virtual care visits at the outset of the COVID-19 pandemic. In addition, the use of telehealth interventions relies on the experiences of clinicians in using the technology as intended [16]. Hence, continuing education can provide new learning opportunities for the best use of telemedicine technologies for geriatric care professionals [22]. 2. Training in the use of telemedicine technologies is needed for older patients, their caregivers, and their families, as well as on how to collect basic health information that may facilitate a telemedicine assessment. This could help alleviate some of the challenges in obtaining clinical information and further enhance the feasibility of virtual care visits without the presence of a health care facilitator with the patient. As McLean et al [11] noted, providing basic training for older patients, their caregivers, and their families could help them better navigate and feel more comfortable in using various telemedicine technologies. 3. Health care systems should maintain virtual care visits as an option available to older patients, their caregivers, and their families, with geriatric care professionals when this option may represent an equally or better way to facilitate care. This recognizes that virtual care visits give older patients, their caregivers, and their families and geriatric care professionals more flexibility to both provide and receive care. It should represent a mechanism through which to provide older patients, their families, and caregivers with the appropriate community infrastructure supports that could help reduce barriers for older patients, their caregivers, and their families in accessing telemedicine technologies. 4. Ensure that future reimbursement models to enable telemedicine or virtual care visits are financially sustainable for geriatric care professionals. Virtual care visits will likely be incorporated into the future provision of geriatric care in Ontario. Hence, temporary payment models will likely transition into long-term ones, and policy makers will need to ensure that the long-term methods of funding the provision of telemedicine-based care are financially sustainable, while ensuring the needs of geriatric care professionals and older persons can also be met.

Conclusion
The sudden need to find alternative ways to provide care in safe and effective ways at the outset of the COVID-19 pandemic forced health care systems worldwide to enable the rapid and widespread adoption and use of telemedicine technologies by geriatric care and other health care professionals. Overall, this study found that Ontario geriatric care professionals could adapt the use of telemedicine technologies to provide virtual care to meet the complex needs of their older patients, but there also exists a threshold in their ability to effectively provide geriatric care using telemedicine technologies. Indeed, geriatric care professionals have been found to perceive telemedicine technologies or virtual care methods to be more appropriate in the provision of follow-up visits that do not usually require specific assessments that are better done in-person. However, this study also noted that there are also various additional issues that will prohibit the greater widespread and permanent adoption of telemedicine technologies in Ontario, especially in the provision of geriatric care, unless specifically addressed. Further research on addressing older patient equity and inclusion, medical information infrastructure, and economic policies will be beneficial for understanding the best practices for supporting the use of telemedicine technologies to provide both more effective and equitable geriatric care.