Virtual Care Initiatives for Older Adults in Australia: Scoping Review

Background There has been a rapid shift toward the adoption of virtual health care services in Australia. It is unknown how widely virtual care has been implemented or evaluated for the care of older adults in Australia. Objective We aimed to review the literature evaluating virtual care initiatives for older adults across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels in Australia. Methods A scoping review of the literature was conducted. We searched MEDLINE, Embase, PsycINFO, CINAHL, AgeLine, and gray literature (January 1, 2011, to March 8, 2021) to identify virtual care initiatives for older Australians (aged ≥65 years). The results were reported according to the World Health Organization’s digital health evaluation framework. Results Among the 6296 documents in the search results, we identified 94 that reported 80 unique virtual care initiatives. Most (69/80, 89%) were at the pilot stage and targeted community-dwelling older adults (64/79, 81%) with chronic diseases (52/80, 65%). The modes of delivery included videoconference, telephone, apps, device or monitoring systems, and web-based technologies. Most initiatives showed either similar or better health and behavioral outcomes compared with in-person care. The key barriers for wider adoption were physical, cognitive, or sensory impairment in older adults and staffing issues, legislative issues, and a lack of motivation among providers. Conclusions Virtual care is a viable model of care to address a wide range of health conditions among older adults in Australia. More embedded and integrative evaluations are needed to ensure that virtually enabled care can be used more widely by older Australians and health care providers.


Introduction
Australia has one of the most complex and decentralized health care systems among the Organisation for Economic Co-operation and Development countries [1,2]. Care decentralization may result in duplication efforts, inefficiency, or poor coordination in service delivery, especially for vulnerable populations and those in rural or remote areas [2]. Virtual care offers a potential solution for streamlining care processes and improving access to care [3]. It is broadly defined as the remote provision of care assisted by information technology [4]. Australia has undergone a rapid shift toward the adoption of virtual health care services in the last 10 years [5]. Strategies to improve uptake of virtual care among older adults may be particularly beneficial, as they are major consumers of health care resources in Australia (30% of unreferred general practitioners and 46% of specialist services in 2019-2020), and are known to experience poor coordination of care [6,7]. Over one-third of older Australians reside in rural or remote areas [8], further compounding problems with access to care.
It is unclear how widely virtual care has been implemented or evaluated in the care of older Australians. There is also a lack of clarity regarding the most appropriate type of virtual care to address the complex health care needs of older people, particularly owing to disability, frailty, long-term health conditions, cognitive decline [9], and higher likelihood of a "digital divide" [10]. Therefore, in this scoping review, we aimed to provide a brief appraisal of virtual care initiatives for older adults in Australia across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels.

Search Strategy
A scoping review methodology was chosen for this review to capture a wide range of virtual care initiatives for the complex care needs of older people in Australia [11]. Five databases (MEDLINE, Embase, PsycINFO, CINAHL, and AgeLine) and gray literature were screened from January 1, 2011, to March 8, 2021, to identify studies evaluating virtual care initiatives for older adults in Australia. The search strategy was built using a combination of subject headings and keywords of the 4 concepts of "virtual care," "initiatives," "older adults," and "Australia" (see Table S1 in Multimedia Appendix 1 for the full search strategy). For gray literature, we used Google Advanced Search and searched key Australian governmental, educational, and organizational domains. We also searched The Analysis & Policy Observatory, Informit, and International HTA Database.

Study Selection
The virtual care initiatives included were limited to those relevant for older adults in Australia. Therefore, any Australian study that exclusively included participants aged ≥65 years or had participants with a mean or median age of ≥65 years or other clearly stated definition of older adults (eg, aged ≥55 years) were eligible for inclusion. Virtual care included any form of technology-mediated care modality including videoconference, telephone or smartphone, device use (including remote monitoring), and other eHealth interventions (eg, apps or websites). Delivery of care included symptom or progress monitoring, education, support, and disease management and treatment. Studies were included if the outcomes were obtained from an older adult's perspective. The inclusion and exclusion criteria are presented in Table S2 in Multimedia Appendix 1.
The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist guided the reporting of this scoping review [12]. Search results were imported into Covidence, and duplicates were removed (see Figure S1 in Multimedia Appendix 1 for PRISMA flowchart). Using a screening checklist, 2 reviewers independently screened the titles and abstracts to identify studies for inclusion. Any discrepancies were resolved through discussion, with consultation from a third reviewer, where needed. The search and screening process was cross-checked by a health information specialist.

Data Extraction
Two reviewers extracted study details from the selected reports using a standardized extraction form. To streamline the scoping review process, a follow-up to study authors was not conducted for missing or incomplete data or information. The following information was extracted: publication details, population characteristics, virtual care details, setting, key findings, and cost assessment (if any). The other key measures extracted were acceptability (for patients or providers), adoption or scalability, and funding source.

Data Analysis
The results were narratively synthesized and presented according to the World Health Organization (WHO) digital health evaluation framework [13]. The WHO framework provides a thorough evaluation guideline of the outputs and impacts of digital health interventions across various domains, including user satisfaction, process improvements, health outcomes, and cost-effectiveness (see Table S3 in Multimedia Appendix 1 for full definitions of each item) [13]. The framework items included in this study were intervention delivery, content, cost assessment, user feedback, and limitation for delivery at scale. A brief synthesis of other evaluation items is provided in Multimedia Appendix 1. The effectiveness of virtual care initiatives was also summarized in terms of health, behavioral, or any health service use outcomes (see Table S2 in Multimedia Appendix 1 for definitions). To note, virtual care initiatives that were delivered as a stand-alone intervention was considered similar or comparable (ie, noninferior) to in-person care if similar outcomes were yielded. The rationale is similar to the measurement of effects in noninferiority trials, wherein if a stand-alone virtual care intervention can provide marginal benefits akin to delivering in-person care alone, then it should be considered at least as effective as in-person (standard) care [14]. However, interventions involving the addition of virtual care to in-person care, compared with in-person care alone, were evaluated for superiority rather than noninferiority [14]. If the combination of virtual care and in-person care does not yield any additional health or behavioral outcome improvements compared with in-person care alone, it was considered inferior, as the intervention (as a whole) cannot compensate for the required extra time, effort, or potential costs to deliver the added virtual care initiative without any additional health benefit and would be no better than delivering a standard care intervention alone.
The initiatives were also grouped according to the following categories: • Communication technologies: initiatives that enable remote interactions between patient and health care provider.
• Information and data sharing: initiatives that facilitate remote sharing of patients' medical and health care information across care providers or relevant stakeholders.
• Remote monitoring: initiatives that use hardware and software to allow remote measurement or documentation of a patient's physiology. The information is either transmitted in real time or stored for subsequent transmission.
We also determined whether the intervention delivery was synchronous (ie, where patient-provider interactions occur in real time), asynchronous (ie, not in real time), or a combination of both. In scoping reviews, assessing the risk of bias in studies is not mandatory, and no risk of bias assessment was conducted for this topic [12].

Overview
Out of 6296 documents, 94 references met the inclusion criteria. We identified 80 unique Australian virtual care initiatives for older adults, of which 9 (11%) initiatives were considered mature (well-embedded or a widely used government-initiated intervention), and others (n=71, 89%) were pilot evaluations (small-scale or feasibility studies). Table 1 provides a summary of the identified initiatives and the key findings of the studies. • Intervention feedback-69% participants were "very satisfied" and 25% "satisfied." Familiarity and support provided by providers were comforting. No demographic or follow-up variables were predictive of greater total satisfaction. However, participants who were older felt they could easily explain their medical problems to the doctor in the video consultation and believed that telemedicine enabled them to save money and time; they were also more likely to report higher overall satisfaction. Age does not appear to be a barrier. Device installations required substantial resources and would not be suitable for high-turnover situations. The lack of broadband internet in some regional and rural areas was a barrier. Initial concerns that equipment would be lost or stolen from patient's homes were unfounded.

•
Higher costs-owing to capital cost and recurrent monthly costs of the tablet for patient use. However, if patient or a family member already owned a tablet, Android device, or PC, then the team was able to load the videoconference software onto it at no cost.
• Improve access to services, selfmanagement of health conditions and health education, and to reduce social isolation • Improved-intention-to-treat analyses indicated between-group superiority of intervention over control on the primary outcomes (self-reported depression severity and general psychological distress), at postintervention and 3-month follow-up, and on secondary osteoarthritis-specific measures (pain, stiffness, and physical function) at the 3-month follow-up. Most intervention participants (84%) no longer met diagnostic criteria at 3month follow-up. Intervention feedback-participants enjoyed the accessibility of the app. The app provided pain self-management instructions, helped diarize self-management plan, and assisted with monitoring progress and planning. Challenges were vision-related when engaging with the app on a small screen, and there were issues of poor dexterity and agility of arthritic fingers. Some expressed concerns that this could lead to overfocus on pain and catastrophizing behaviors.
• • Feasible-patients and carers were able to use the technology and did self-report using the apps. There were 611 alerts arising from changes in performance score across the study and 4386 alerts generated through symptom assessment scale. Self-reported data entered by patients and carers did identify changes in performance state and in symptom distress, triggering alerts to the service provider. Scheduled videocall contacts and contacts made in response to triggers led to changes in care. Improved-a small reduction in public hospital admissions and clinical complexity of both public and private hospital episodes for some participants, smaller increases in the use of general practice health services vs control, and improved quality of care through earlier identification of health issues and medication management. Participants improved health literacy and self-management, leading to a more cooperative approach to health management, improved relationships between participants and their practice, and an overall improved sense of assurance and well-being and helped delay entry into residential aged care facility. • Cost-effective (but not for entire cohort)-an overall cost-effective analysis based on the operation of the trial model, excluding trial set-up costs, showed operation as a service in the future could be cost neutral. Other qualitative analysis indicated that value for money is more likely to be achieved as a short to medium-term intervention for appropriate participants in appropriate clinical settings. • Improved-most participants reported that the intervention increased physical activity levels, embedded activities, and generated positivity about physical activity. They were motivated by quantified physical activity feedback, self-directed goals, and personcentered coaching. Social connectivity motivated some, but the intervention did not support this well.
• Promote physical activity and preventing falls • Not effective-no difference in overall step counts and quality of life between groups, but telephone and pedometer groups maintained daily step counts, and standard care showed a reduction over 12 months. Unexpected findings included significantly higher diastolic blood pressure in pedometer group than standard care, and 10-time sit-to-stand was significantly slower on the telephone group compared with standard care.
• Assist ongoing support to maintain physical activity levels and health outcomes Not effective-no difference in medication adherence but mean systolic blood pressure was reduced in the intervention group at 9 months postintervention. Participants enjoyed being more actively engaged in self-management with minimal inconvenience or cost to their routine.
• Improve blood pressure control and medication adherence in adults with coexisting diabetes and chronic kidney disease • Mixed evaluation-home visit, self-monitoring of blood pressure, individualized medication review, 20-minute offline video education and telephone followup support (12 weeks), evaluated at 3, 6, and 9 months after the intervention. • Noninferior-the model successfully treated patients effectively and safely. Participants had similar lengths of stay to those cared for in regional hospital, and most were able to be safely discharged home.

•
Cost-effective-cost comparison showed similar outcomes, with similar per bed day costs achieved in regional hospital vs the rural center. Specialist medical input was provided cheaply using videoconference. Use of beds at the rural center to increase from 50% to 80% after 2 years.
• Improve patient care in rural centers by improving care flow and management, improve bed occupancy rate, and reduce pressure on regional hospital • Secondary-videoconference for a weekly case conference between health care team at the rural hospital or patients and geriatrician at a regional hospital plus on-site geriatric care in the rural center • Communication technologies, synchronous, pilot • Same intervention model but in regional hospital (already established before study) •

Intervention Delivery
Most initiatives were delivered for community-dwelling older adults at home (64/80, 80%; Figure 1). Six initiatives were for older adults in residential aged care facilities, 8 were delivered in hospital, and 2 included older people in the community, residential aged care facilities, or in-hospital settings. Videoconference (n=28), telephone (n=29), and telemonitoring systems (n=15) were the most commonly used modes of delivery ( Figure 1).
For initiatives that facilitated "information and data sharing," 2 involved sharing of medical information from electronic records [71,74], whereas others involved older adults either taking measurements (eg, blood pressure, weight, height, or other physiological data) using devices attached to a portal, which were automatically transmitted to care providers (n=11) [80][81][82]84,85,[87][88][89][90][91][92][93][94][95][96] using devices or wearables that automatically recorded and transmitted data (eg, activity trackers; n=2) [98,100], or manually entering data without using any device or wearable (n=2; Table 1) [83,86]. Characteristics of virtual care initiatives for older Australians (n=80), including by type of modality, location, which health care professional leads or has direct involvement with the virtual care, the essential mechanism or function that underpins the initiative (and including whether the mode of delivery was synchronous, asynchronous, or both-shaded in blue), the setting in which the initiatives were delivered, and the disease domain. NSW: New South Wales; QLD: Queensland; SA: South Australia; TAS: Tasmania; VIC: Victoria; WA: Western Australia.

Effectiveness
Of all identified initiatives, 34 (43.8%) randomized controlled trials and 3 (3.8%) implementation studies evaluated effectiveness for health or behavioral changes compared with in-person care or other suitable comparators.
An app-based study reported higher ambulance use; however, this was owing to the improved recognition of heart attack symptoms [78].
In total, 9 virtual care initiatives were delivered as an add-on to standard (in-person) care, only 2 of which reported similar or better outcomes compared with standard care alone. Two initiatives using telephone-based support plus pedometer-based biofeedback, in addition to standard care, resulted in similar physical activity [98,100] and quality of life [100] compared with standard care alone. Only 1 study reported higher physical activity using such an intervention versus standard care alone [101]. Similarly, telephone-based interventions as an adjunct to in-hospital standard care (n=4), home visit (n=1) or various mixed-mode interventions (n=1) did not result in any additional or improved health outcomes [103,107,109], quality of life [105,[109][110][111], and emergency department presentation [107,110,111] and hospitalization compared with standard care alone [107,111]. Incorporating videoconferences in rural centers as an add-on to in-person care yielded similar health outcomes to their regional hospital counterparts [104].

Cost Assessment
In total, 18 studies reported cost-related assessments (Table 1). Virtual care was associated with lower travel costs for patients [19,26,36] and higher savings for providers from reduced health service use [51,84,93,94]. Two modeling studies of a virtual (telephone-based) emergency department and a remote monitoring initiative indicated that higher implementation rates would lead to more cost-saving effects [51,93]. However, virtual care was associated with high set-up [23,45], maintenance [23,45], and staffing costs [31,50]. Four virtual care initiatives resulted in lower per-patient delivery costs [26,59,75,104] and staff wages [26], while 4 studies reported higher per-patient delivery costs [15,31,50,94]. A virtual dental care initiative demonstrated that remote synchronous (real-time) oral examination was more expensive than face-to-face examination for every aged care facility resident, while an asynchronous review and treatment plan was cheaper than both synchronous and face-to-face delivery modes [31].
Four studies reported the incremental cost-effectiveness ratio (ICER) from the provider's perspective (Table 1). A videoconference initiative for telerehabilitation was cost saving with an ICER of Aus $4157 (US $2782.57) per quality-adjusted life years gained compared with center-based (in-person) care [44]. Virtual cognitive behavioral therapies yielded an ICER of Aus $50,284 (US $33,665.69) per quality-adjusted life years delivered using telephone compared with in-person befriending [53] and Aus $4392 (US $2940.4) when delivered via the web versus a waitlist control group [70]. Compared with a standard in-hospital consultation, a home visit plus telephone follow-up intervention yielded an ICER of Aus $61,906 (US $41,446) for every older person with a clinically meaningful improvement in daily activities [108].

Technology-Related Issues
Interface-related issues highlighted by older people include a lack of audio or visual clarity [16,[24][25][26]76] and discomfort because of poor dexterity and agility when engaging with virtual care devices [76]. One qualitative study highlighted a lack of consensus regarding the ideal interface, functionality, and size of wearables (pedometers) [99]. In one multimode study, only 54% of patients understood how to access web links provided within database-fed messages [75].

Usability and Boundaries
Videoconference was deemed appropriate for educational sessions and other talking-based therapies [20] and to assess visually striking conditions (eg, wounds, ulcers, and edema) [88]. It was less useful when a hands-on approach is needed, such as for oral preventive care [30,31], physiotherapy or other active rehabilitative procedures [20,83], and for selected health conditions (eg, pneumonia) [35]. Clinicians have highlighted difficulties using videoconference when patients exhibited significant cognitive, sensory, and physical impairment [16,17,19,41,42]. Patients did not find some virtual educational or support interventions useful if they were already familiar with their conditions or if they had a straightforward recovery process (for post-discharge interventions) [65,84,110].

Access for Individual Participants
A stable technology platform and appropriate physical environment were critical for telemonitoring [80,81,87]. Adherence among older people was facilitated by rapid feedback and access to providers when needed and the availability and clarity of protocols for missed readings or data entry [96]. For web-based initiatives, the key enablers for older adults were previous internet self-efficacy and, when compared with the younger population, higher leisure time to interact with web features and willingness to invest time in health [64]. For providers, flexible as well as appropriate funding and reimbursement were crucial [39,80,81].
From the providers' perspective, a key challenge was staffing issues (n=6), including insufficient staff to run the modality [17,19,39], and a need for additional support owing to low staff digital literacy and change in common practice [35,83]. Another challenge included a lack of motivation among providers to use new technology (n=5) [17,20,33,39,94]. Management and relationship challenges were noted in residential aged care settings (n=3), driven by poor infrastructure, short project turnaround time, and high turnover of staff [35,39,116]. There were reports of complex mandates at various levels of government [35,94] and frustration with virtual care policies [39].

Other WHO Digital Health Framework Items
A brief synthesis of technology and platform, adaptability, interoperability, replicability, data security, and regulatory compliance is provided in Multimedia Appendix 1. In total, 17 initiatives reported integrating virtual care into existing infrastructure and systems. No studies have reported issues regarding interoperability. However, this does not mean interoperability with existing systems was not an issue but that integration is often outside the capability and capacity of the research and operational teams. Most initiatives were funded by federal agencies (n=52) or state agencies (n=16), and a small number were funded by commercial or nonprofit organizations (Multimedia Appendix 1).

Overview of Evidence of Virtual Care Use for Older Australians
This scoping review identified a wide range of virtual care modalities used for diverse care purposes and disease domains in older patients that have been tested or implemented in Australia. Across the 80 identified initiatives, older Australians were highly accepting of virtual care, in agreement with a recent survey [117]. Older Australians reported improved access to care, time efficiency, and self-management capacity in alignment with reviews of other modality-or disease-specific virtual care [118,119]. It remains challenging to define the exact use cases for the different virtual care modalities because of the variations in measured health or behavioral outcomes, patient conditions, frequency of use, and others. However, videoconference appears to be appropriate for most talking-based therapies and diagnosing visually evident conditions [20,88] and inappropriate for care needing hands-on approaches [20,30,31,35,83]. Telemonitoring or device use are appropriate options for interventions intended for self-management and monitoring, particularly for older adults with chronic diseases [84,86,96,115]. Web-based interventions and apps are convenient modalities for asynchronous delivery of information or educational interventions provided older people-friendly features are present (eg, large fonts) [64,72,76,99]. The findings of telephone interventions were most inconsistent, but the modality is widely used for follow-up calls and health coaching. Importantly, most studies we reviewed suggest that when delivered as a stand-alone intervention, the virtual care delivery model may yield comparable outcomes to in-person care when care needs and modality are aligned.

Practical Considerations of Virtually Enabled Care for Older Adults
Clinical indications for the use and boundaries of various virtual care modalities for older Australians generally echoed studies from other countries [120] and of the general population [121]. However, for older people, interface design should be user-friendly [16,[24][25][26]28,76] and must cater to potential cognitive, sensory, and physical impairments [16,17,19,41,42]. The reduced engagement of older Australians over time should also be anticipated across modalities [63,83], as has been identified globally [122]. Reasons are poorly reported; however, this may be attributable to high effectiveness (leading to early disengagement), as reported in a US study [123], or a lack thereof [48,98,100,103,105,107,[109][110][111]. Altogether, these findings suggest the importance of engaging older adults across all stages of initiative development (ie, using a co-design approach; Figure 2). A growing commercial interest in digital health in Australia may also lead to a wider variety of options for equipment and technology in the near future [124].

Older Australians Are Ready to Be Digitally Equipped and Use Virtual Care
Many older adults want to sustain their independence and self-manage their health [7]. This may explain the indications for higher engagement in older versus young people [64,72,73]. While lack of technical literacy in older people remains an issue globally [118,119,125] and in Australia [64,65], this is likely modifiable. For example, studies in our review [35,36,84,86,93,95,96] and in another similar review [126] suggest that equipment training and clear protocols for independent activities (eg, data entry) may help reduce anxiety and negative perceptions toward new technology and improve adherence ( Figure 2). Internet literacy rates among older Australians have also improved (6% in 2001 and 79% in 2015) [127], with a survey in 2018 indicating "unnecessity" (80%) as the reason for no internet use in the last 3 months versus 20% for "no confidence/knowledge" [128]. Therefore, while the digital divide still exists among older Australians, advanced age is unlikely to be the main barrier to virtual care use [45,93].

While Older Adults Are Ready for Virtual Care, Challenges Faced by Providers Remain
Staffing, bureaucracy, and management issues were identified as challenges by Australian providers and are echoed globally [129,130]. These barriers have been reported together with a lack of motivation among providers [17,39], suggesting that they go hand in hand. Interestingly, low digital literacy among staff has been observed, leading to the need for recurrent training [35]. Indeed, digital literacy criteria are not an integral part of staff recruitment for Australian care providers [131], highlighting the importance of implementation of digital health education strategy [132]. Furthermore, only a quarter of all initiatives evaluated a cost-related component, wherein recurring staff training and logistics were large contributors to capital costs [23,30,31,45,50,59,84,93]. More cost-related data are needed to robustly inform decision-making, including for scale-up considerations.

There Is a Need for Digital Health Policy Surrounding Virtual Care for Older People
Most identified studies were early-stage (pilot) evaluations, highlighting the need for a larger body of evidence from sustained and integrated implementation trials. We also found limited cost-related data or economic evaluations, which are important parameters to inform wider adoption of virtual care services. Therefore, institutions and care providers may benefit from the provision of set standards or guidelines for virtually enabled care of older people. Such guidelines currently do not exist in Australia. The Aged Care Industry Information Technology Council report, which summarized technological innovations across the globe, as well as key learnings from this review, may serve as starting points [133]. There should also be strong recommendations for the collection and evaluation of critical data (eg, clinical, legislative, and economic data) to appropriately inform, fund, and mobilize virtual care services.
The key recommendations are summarized in Figure 2.

Strengths and Limitations
The strength of this review is that it brings together the evidence of the broad range of virtual care modalities tested to support older adults in managing their chronic health conditions. These findings are also likely relevant for other countries with a similar demographic profile (ie, aging populations and high-income countries) or technological aptitude among their older populations [134] and for countries at a similar stage of digital health adoption [135].
The limitations of this study are as follows: to ensure a wide coverage of references and timely identification of evidence, we only included articles from the past 10 years. In terms of the evidence pooled, we included studies with varying definitions of older adults; thus, generalizations may not apply to all older adult populations (eg, people in their 70s may have very different well-being and technological characteristics compared with those in their 50s or 60s) [136]. There is also a large heterogeneity across studies and outcomes reported in this scoping review, which makes it challenging to draw sweeping conclusions about one modality or population against another. A network meta-analysis may be a suitable next step to examine all the comparisons for different elements that could be included in virtual care interventions and control conditions. Finally, conclusions drawn from randomized controlled trials in the context of virtual care are often subject to publication bias. Nevertheless, this review provides critical first steps to develop a virtual care policy for older people, particularly in terms of key elements for consideration of surrounding modality selection, interface considerations, and need for guideline development and sustained evaluations.

Conclusions
This review identified that there are a wide range of virtual care modalities designed to enable older adults to manage their chronic health conditions. The identified barriers to wider adoption were attributable to physical, cognitive, or sensory impairment at the patient level and staffing, legislative, and motivational issues among providers at the system level. More evidence from embedded and integrative evaluations are needed to ensure virtually enabled care can be used more widely and efficiently by providers and older Australians.