Nabha Shetty, MD, FRCPC, MSc1,2, Tanya MacLeod, MSc3, Ashley Paige Miller, MD, FRCPC, MSc1,2, Melissa Buckler, MA2, Laurie Mallery, MD, FRCPC, MSM1,2, Anne-Marie Krueger-Naug, MD, FRCPC, PhD1,2, Maia von Maltzahn, MD, FRCPC1,2, Paige Moorhouse, MD, FRCPC, MSc, MSM, CHE1,2
1Dalhousie University, Faculty of Medicine, Department of Medicine, Halifax
2Nova Scotia Health Authority, Halifax
3Dalhousie University, Faculty of Medicine, Continuing Professional Development and Medical Education, Halifax, NSDOI: https://doi.org/10.5770/cgj.28.759
ABSTRACT
Background
During the COVID-19 pandemic, long-term care (LTC) facilities faced challenges in establishing appropriate goals of care (GoC) for residents during health crises. To address this, a virtual specialist consultation program was implemented to align care interventions with residents’ frailty and expected outcomes.
Methods
We explored barriers and enablers to the implementation and sustainability of the program using structured interviews (n=20) with LTC leadership, health-care staff, and members of the program. Data were coded according to the constructs of the Consolidated Framework for Implementation Research (CFIR) using thematic analysis.
Results
Participants described how the program improved care and reduced unnecessary transfers. Implementation was enabled by a high degree of tension for change, relative priority, relative advantage, and the team’s shared mental model of frailty-care. Inconsistencies in GoC approaches and information silos between LTC and acute-care challenged implementation. Sustainability was hindered by decreased pandemic urgency, resulting in reallocation of resources to usual care. The need for a specialized GoC service in LTC became less obvious outside of a crisis.
Conclusions
This implementation study provides important insights for future spread and scale of embedding virtual specialist consultation services into LTC. The findings underscore the importance of collegial relationships and shared care philosophies to effectively implement frailty-informed care initiatives during crises. However, sustaining cross-sectoral GoC services may be challenging amidst evolving workloads and prevailing cultural perceptions of end-of-life care needs.
Key words: implementation science, consolidated framework for implementation research, frailty-informed care, virtual care, specialist care teams, goals of care, advanced care planning in long-term care
The first wave of the coronavirus pandemic (COVID-19) posed a significant risk to older adults living in long-term (LTC) facilities.(1) Most LTC residents have a high degree of frailty,(2) defined as the lifelong accumulation of health deficits leading to a decline in function, mobility, and/or cognition.(3) Frailty increases vulnerability to poor outcomes from acute illness, as evidenced during the first wave of COVID-19 in Canada, where 81% of deaths were among older adults in LTC facilities.(4) The severity of outbreaks in LTC highlighted the urgent need for policy change to better support the LTC sector,(5) including “care-in-place” protocols to mitigate overwhelming hospital resources. These protocols aimed to discourage unnecessary transfers of frail LTC residents with COVID-19 to hospitals, focusing instead on improving on-site care for those unlikely to benefit from critical care interventions.(6–8)
During the first wave of the pandemic, health-care leaders launched various initiatives to enhance care, improve communication, and increase resources for frailty-informed care.(9) In Ontario, Canada, the LTC Plus collaborative care program used virtual general internal medicine consultations, nursing navigator support, rapid diagnostic access, and educational resources, to enhance nursing home care and reductions in unnecessary acute care transfers during the pandemic.(10) In Nova Scotia, Canada, our team of six academic internists (NS, LM, APM, AMKN, MvM, PM) developed and studied the impact of the MED-LTC program which offered virtual internist and specialist nurse practitioner consultation to inform and update goals of care (GoC) for LTC residents. The MED-LTC approach to care planning was based on the Palliative and Therapeutic Harmonization (PATH) approach to frailty-informed care and the best available evidence at the time of implementation.(11)
The MED-LTC program had four objectives:
The program resulted in decisions for less aggressive care. Post-consultation, 83% (52 of 63) of participating long-term care residents (or their decision-makers) de-escalated care plans. Sixty-two per cent decided against hospitalization compared to 7% pre-consultation. Notably, these patients had previously undergone a conventional care-planning process, reinforcing the principle that sharing detailed information about an individual’s health status changes decisions.(6)
This paper presents a qualitative post-implementation study that systematically explored the effectiveness and sustainability of the MED-LTC program.
This retrospective, qualitative study employed structured interviews with the implementation team, LTC staff, and LTC leadership to gather data about the MED-LTC program after it had ended. The primary objective was to identify factors supporting implementation to inform ongoing collaboration for frailty-informed care delivery. The study was approved by the Nova Scotia Health Authority Research Ethics Board, Ref No. 26635.
We used the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis, as this framework considers micro-, meso-, and macro-level factors in program implementation and the implementation process itself.(12) The framework describes constructs known to influence implementation success across five domains: intervention characteristics, outer setting, inner setting, characteristics of individuals, and the process used for implementation. We used the most recent version of the CFIR available at the time of the study;(12) however, theory building is an iterative process and updated versions of the framework have been published since we completed our research.(13)
The interviewers were graduate-level evaluation specialists (TM-author, AM). The lead qualitative analyst (TM) has over 15 years of qualitative research experience and has published in the field of frailty care. Interviews were conducted by phone or video call, with an email response option for those unable to participate in an interview. Interviewees and email respondents received the same set of questions as found in the interview guide (see Appendix A).
Data from interviews and emails were recorded, transcribed, and de-identified before being uploaded into NVivo 12 (QSR International (Americas) Inc., Burlington, MA) for analysis using the CFIR coding template.(14) An NVivo project template with pre-populated CFIR codes and queries was provided by the authors of the CFIR and used to map responses to each construct. Team members (TM, PM, LM, NS, AMKN, MB) worked in pairs to code interview transcripts to each construct. The interpretation of the constructs from each analysis file was further refined by a smaller working group (NS, PM, TM, MB). Post-coding, a thematic analysis on ‘sustainability’ was conducted by pulling data from each domain since this theme was not captured in the initial version of the CFIR used for this study. Domain summaries included dominant CFIR constructs in brackets.
Twenty participants were recruited (17 interviews, 3 email responses) including: seven MED-LTC clinicians, four administrative members, and nine LTC staff, including leadership, from four LTC facilities. Participant characteristics are outlined in Table 1.
TABLE 1 Participant characteristics
A summary of each domain’s prevailing themes and constructs with representative quotes is provided in Table 2.
TABLE 2 Summary of themes, constructs, and representative quotes by domain
Advocacy for care-in-place strategies for frail residents in LTC, along with the rollout of virtual care fee-codes and the automatic registration of the province’s specialists with video conferencing accounts enabled the program’s implementation (patient needs and resources). The pre-program provision of frailty care was described as siloed. There was significant variability in the quality and accessibility of GoC documentation, both within facilities and to health sectors outside LTC, presenting challenges to MED-LTC clinicians. A MED-LTC member described an instance where a LTC resident with a “care-in-place” goal was nonetheless transferred to hospital. The MED-LTC member who completed this patient’s GoC was not called by hospital staff (cosmopolitanism).
An outbreak in a large LTC facility spurred implementation, driven by the challenges of managing GoC while concurrently caring for infected residents (tension for change, relative priority). The shared commitment to holistic care-planning among LTC facilities and MED-LTC clinicians facilitated a positive reception for the program, aligning with existing values and practices (compatibility, culture). Leadership engagement in establishing the role and timing of MED-LTC consultations helped introduce the service to LTC PCPs. The program addressed a gap in the granularity of LTC GoC documentation, adding details about specific goals, such as whether a resident would accept intubation and intravenous therapies. This intervention became particularly critical as facilities prepared for an increase in care transitions during the pandemic (relative priority, tension for change). Granting MED-LTC access to the LTC electronic medical record was considered a significant enabler by both the MED-LTC and LTC clinicians (networks and communication). Pre-consult communication between MED-LTC and LTC PCPs, when it occurred, helped lay the groundwork for subsequent robust GoC discussions. In hindsight, MED-LTC team felt that building rapport and trust with the LTC team before implementation would have benefitted the program (networks and communication).
The immediate implementation of the program addressed an urgent need in LTC (intervention source) but posed a barrier to thoughtful and measured program design (trialability). Given their experience working with frailty and acute care, the MED-LTC team integrated emerging evidence for COVID-19 care with GoC planning for LTC residents (adaptability, relative advantage, evidence strength, and quality). The program used a validated, structured, frailty-informed approach to GoC discussions. Each consultation involved several hours of physician time and included a detailed review of health history, function, and cognition using chart review and collateral interviews. This initiative reduced the time and resources LTC providers needed to spend on complex care planning, allowing them to focus on direct care for infected residents (relative advantage). LTC staff indicated that families were more accepting of specialist recommendations about de-escalating GoC compared to usual care-planning processes (relative advantage).
MED-LTC team members worked in an academic Department of Medicine in an urban tertiary care centre. Pre-established approaches to care and working relationships among team members had the most significant influence on implementation (compatibility). The ability to connect with colleagues who shared a similar philosophy of care within a “culture of call”—an environment where physicians consult and support each other—was an important incentive (networks and communication). MED-LTC clinicians described the program as a grassroots initiative that disrupted an organizational culture where non-beneficial interventions are often offered to frail, older adults (culture).
For this domain, the “individual” was coded as the entire MED-LTC team. The most influential enabler was the team’s prior collaborative experience and shared approach to GoC (knowledge & beliefs about the intervention, self-efficacy). MED-LTC members self-identified as frailty experts who worked in acute care and routinely navigated complex decision-making (individual stage of change, preparation, individual identification with the organization). Adapting this work to LTC virtual consultations was a professionally rewarding contribution to the pandemic response.
Program planning started with casual “what if” conversations that quickly evolved into formalized team meetings among existing social and professional networks when an outbreak was declared in a LTC facility (engagement, planning). The program was piloted with a small number of residents, which created trust between teams to move forward with broader implementation. Program delivery was impacted by variability in LTCs’ human resources and technology access, which presented challenges for scheduling and information gathering (executing). Administrative support for scheduling came from diverted specialist resources and was an important enabler (planning). The team adapted program elements based on scheduled and informal debriefs.
There was an evolving understanding of the program as implementation occurred. One team member likened the experience to ‘building the plane as we were flying it’. MED-LTC members perceived a declining demand for the program with outbreak resolution. LTC providers perceived that, in the absence of a crisis, existing care-planning processes were adequate. However, LTC leadership and staff expressed a need for ongoing remote consultation service for complex GoC discussions and other health concerns. While the team initially supported requests for non-COVID-19 consultations (adaptability), the resolution of the first COVID-19 wave resulted in the resumption of routine work, which limited capacity for MED-LTC activities and ultimately led to the program’s closure. To aid in future iterations of similar programming, we present a summary of implementation recommendations for sustainability in Table 3.
TABLE 3 Implementation checklist for a Virtual Goals of Care (GoC) consultation service for long-term care (LTC)
The MED-LTC program provided a structured approach to virtual, specialist-supported GoC discussions in LTC. This study examined the barriers and enablers of implementation. Implementation was enabled by a high degree of tension for change, relative priority, relative advantage, and personal attributes including a shared vision grounded in pre-existing social bonds and the team’s mental model of frailty-care. The program’s success was also due to (i) rapid program set up/delivery, facilitated by reallocating human resources from usual care; (ii) providing technologically agile care; (iii) collaboration between MED-LTC and LTC staff/facilities; and (iv) unrestrained organizational support. The MED-LTC program objectives dovetailed with several circumstances including: the urgency of COVID-19 outbreaks in LTC; longstanding LTC resourcing shortfalls; and pandemic related “care-in-place” directives. The familiarity of MED-LTC members with the PATH framework,(11,15) coupled with pre-existing relationships and a shared desire to improve frailty care were crucial factors in the success of the intervention.
Implementation of the MED-LTC program faced several systemic challenges. Key barriers included inconsistencies in access to—and quality of—GoC documentation across LTC facilities, information silos between LTC and acute-care, and differences in approaches to care planning, such as the extent to which decision-makers were informed about upcoming GoC discussions. These issues align with previously described obstacles to providing optimal end-of-life care in LTC settings.(16)
The vulnerability of LTC residents related to COVID-19 infection also highlighted the need for effective care-planning frameworks.(17) The MED-LTC program addressed the need for specialized communication for GoC planning during the pandemic with virtual consultations that used the PATH framework to foster communication, information-delivery, and shared decision-making for frailty-informed care. Health-care providers working in long-term care settings should receive training and support to use validated approaches to GoC conversations and tools that support care planning in LTC populations. For instance, RESPECT-LTC (Risk Evaluation for Support: Predictions for Elder-life in the Community Tool in Long-Term Care) identifies palliative care needs, enhances communication about prognosis, and supports more personalized and patient-oriented care planning. Early findings indicate that education, particularly training on conducting serious illness conversations, significantly improved physicians’ and nurses’ confidence and comfort in discussing goals, values, and wishes with residents and care partners.(9) Since the pandemic, models have been developed to encourage GoC conversations led by interprofessional teams rather than relying solely on physicians and nurse practitioners. Cranley et al. highlight that involving LTC staff, such as personal support workers, can promote shared decision-making and individualized care in LTC settings. This interprofessional approach leverages diverse expertise for shared decision-making, while physicians and nurse practitioners provide deeper insights into residents’ medical conditions, enhancing decision quality.(18)
In addition to efforts to enhance care planning, interventions also emerged to support care-in-place directives during the pandemic. These initiatives aimed to reduce unnecessary hospital transfers and enhance on-site care. The LTC Plus program, for example, utilized a hub-and-spoke model with a virtual Nurse Practitioner resource navigator and provided internist support to LTC staff, thereby improving the quality of care in LTC facilities.(10) Wyer et al. found that improved communication between LTC and emergency department physicians reduced the number of transfers from LTC to hospitals during the pandemic.(8)
A central feature of innovation during COVID-19 was the ability to connect providers and patients in the virtual space. Our results reinforce the effectiveness of telemedicine for conducting GoC discussions. Likewise, virtual GoC planning has successfully been delivered in inpatient settings when visitor restrictions limit patient access.(19,20) Connelly et al. also explored the impact of using multidisciplinary team video conferencing to implement an evidence-based intervention during COVID in two LTC facilities. The study found that adopting the virtual program effectively addressed residents’ needs and responsive behaviours.(21)
The MED-LTC program’s sustainability was challenged by increased complexity, cost, and lessened relative priority in the post-acute phase of COVID-19. Despite its significant impact, the insufficient investment in protecting the resources needed to coordinate frailty-informed care between sectors led to program closure. It is therefore unclear whether the acceptance and efficacy of virtual GoC discussions in LTC could persist outside of restrictive circumstances. There is opportunity for further research on the factors supporting the sustainability of virtual GoC programming and the impact of a working group’s collective values and trust on implementation success.
The MED-LTC implementation study provides important insights to support the future spread and scale of embedding virtual specialist consultation services into LTC. This study is proof of concept that GoC programming can be delivered virtually by specialist physicians in community settings. The analysis underscores the importance of collegial relationships and shared care philosophies to effectively implement frailty-informed care initiatives during health-care emergencies. However, sustaining cross-sectoral GoC services may be challenging amidst evolving workloads and prevailing cultural perceptions of end-of-life care needs. This implementation science study of the MED-LTC program describes the enabling and impeding factors that support the use of a structured, virtual GoC discussion to reduce unnecessary transfers to hospital and promote frailty aligned care plans.
We would like to acknowledge the contributions of NP Amanda Tinning MED-LTC clinician, Dr. Barry Clarke, Medical Director for Northwood LTC facility and the staff at the facility for their contributions to the implementation of the MED-LTC program, and Anne Mahalik for conducting interviews.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare the following interests: Drs Laurie Mallery and Paige Moorhouse are co-founders of the Palliative and Therapeutic Harmonization clinic (www.pathclinic.ca)
This research was generously supported by Nova Scotia COVID-19 Health Research Coalition.
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Correspondence to: Nabha Shetty, MD, FRCPC, MSc, 1276 South Park Street, 4,th floor Bethune Building, Halifax, NS, Canada, B3P 1Y9, E-mail: Nabha.shetty@nshealth.ca
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 28, No. 1, MARCH 2025