Background
Methods
Setting and context
High Risk | Any of: • Age 60 or over • Presence of one or more co-morbidities associated with increased mortality (cardiovascular disease, chronic lung conditions, hypertension, diabetes mellitus, cancer, chronic kidney disease, obesity) • Immunosuppression • Aboriginal or Torres Strait Islander • Pregnant women • Socially isolated / vulnerable (including individuals who are psychosocially complex or have limited self-management skills) • Frailty • A person discharged after an acute inpatient admission at NH (this does not include patients discharged directly from the Emergency Department) • A person who has had a 000 call due to COVID-19 symptoms • Moderate to severe COVID-19 symptoms • A person whom clinical judgement/clinician worry identifies at being at higher risk (e.g. shortness of breath associated with infection) |
Low Risk | • Under 60 years of age • No co-morbidities • Nil known immunosuppression • Mild COVID-19 symptoms |
Ethics approval
Measures
Staff experience
Question Prompts | CFIR Domain & Construct/s |
---|---|
Can you describe your role in the COVID-19 Community Monitoring Service? | Process; all constructs |
How confident are you that the COVID-19 Community Monitoring Service is responding to individual and community needs during the pandemic? What gives you that level of confidence (or lack of confidence)? | Characteristics of individuals; all constructs |
Did the service work for all patients that were approached? Why/ why not? | Process: planning + reflecting and evaluating |
Tell me about the supports, materials, or toolkits that were available to help you in your role within the service? How do you access these materials? | Intervention; design quality Outer setting; patient needs & resources |
What are the most important benefits that have been achieved with this service? To what extend has the patient/clients’ needs been met? How do you know these are benefits? Have there been any unintended consequences? Can you tell us any stories about the patient experience that stand out for you? | Intervention characteristics; all constructs |
Do you believe the majority of the staff on the team are happy with how the service operates? Describe | Characteristics of individuals:;all constructs Inner setting; culture + compatibility |
Do you believe the majority of the patients that were provided care were happy with the service? Describe | Intervention characteristics; all constructs |
If the COVID-19 pandemic continues at current numbers can this service change continue to be delivered in this format consistently moving forward? Why/why not (Prompt) Does this intervention fit within our health service/ health system? Is it feasible to continue? | Intervention characteristics; adaptability + structural |
What kinds of changes or alterations did you need to make to the service to work more effectively (as telehealth delivery/other) as the service has evolved? | Process – executing, reflecting, evaluating |
Patient experience
Participant recruitment
Staff experience
Discipline | Number of participants (n = 15) | % female | % direct care team |
---|---|---|---|
Allied Health | 5 | 80% | 60% |
Nursing | 9 | 100% | 78% |
Medical | 1 | 0% | 100% |
Patient experience
Analysis
Staff experience
Patient experience
Data reporting
Results
Staff experience
Theme | Sub-theme | Example quote | CFIR Domain | Construct |
---|---|---|---|---|
THEME 1: Service commissioning enablers | Command centre/ Division of labour | ‘I played to people’s strengths or areas and used a command centre approach [to service establishment].’ Interview 11 | Inner Setting | Leadership engagement |
Relative priority | ||||
Redeployment of frontline personnel furloughed due to health concerns | ‘We were able to redeploy staff who were pregnant or who had health concerns that would put them at risk if they staying working on the front line.’ – Interview 13 | Inner Setting | Available resources | |
Dynamic and flexible approach to change | ‘We had huddles twice a day with the group as well as the leadership team… it was through those huddles we [made] continual changes to that procedure.’ – Interview 14 | Intervention characteristics | Adaptability | |
Rapid development of policy and procedures and centralised access | ‘They created a shared drive which the majority of our information went into; introduction packages that we sent to patients [etc.]. The policy itself is on Prompt [hospital intranet], templates we used when speaking with patients, so that its consistent … was emailed … and was on the [shared] drive so you could access it yourself, and as they got updated, they emailed all of us so that way if there were any changes we knew straight away.’ – Interview 1 | Outer Setting | Patient needs and resources | |
Inner Setting | Networks and communications + Available resources + Access to Knowledge & information | |||
THEME 1: Service commissioning challenges | Inadequate staffing initially to meet demand | ‘One of the memories that I have is when we started it was right sort of as that peak was really hotting up and we had three staff at that point.’ – Interview 13 | Inner setting | Readiness for implementation |
Sporadic commencement of staff | ‘We had staff starting on different days. This meant I kept being taken away from the call centre to train the new staff when we were really busy. This could be improved by having staff all start on the same day.’—Interview 4 | Process | Planning | |
THEME 2: Service delivery perceived benefits for patients | Managing deterioration | ‘When I called to talk to him his wife answered the phone and she said he can’t talk at the moment, he’s really sick and I’m trying to get him to the hospital, can I talk to you later on. I said no I can actually help you, do you need some help? She explained the situation … that she was trying to get him to hospital and she couldn't. I offered to speak to her husband and managed to have bit of a conversation with him and built a rapport. I built up enough trust with him that he then let me call an ambulance for him.’ – Interview 1 | Characteristics of individuals | Knowledge and Beliefs about the Intervention |
Support to self-isolate safely and reduce household transmission | ‘We were providing … advice … around how to isolate safely at home away from other people, like good hand hygiene, separation from other members of the household, when and wear a mask, how to safely move about the house to reduce the risk of household spread.’ – Interview 2 | Characteristics of individuals | Self-efficacy | |
The service was the best service- because we had no friends or family support, you gave us good advice on how to isolate to prevent the spread of the virus- Patient survey respondent 168 | ||||
Welfare checks | ‘I had one patient that I’d been following up every day for a good 4 or 5 days and one of the days that I rang her, probably about 15 min later than normal, she said “I’ve been waiting for your to call. You make my day.”’ – Interview 6 | Characteristics of individuals | Individual stage of change | |
Provision of information and clarification | ‘There’s a lot of people who don’t know what to do. Information is very limited so even when we tell them to do this and that, sometimes they would get surprised and go “oh I can go out” and I say no because you’re a close contact of this patient so basically you need to be home as well until that patient is cleared. There was some confusion…’ – Interview 7 | Characteristics of individuals | Other personal attributes | |
Information provided in language | ‘We focused on [people] who don’t speak English and got a person … to interpret. Sometimes one of the family members interprets and that is not appropriate so we provided telephone interpreting services and [translators] locally through Northern Health. That worked very well.’ – Interview 1 | Characteristics of individuals | Access to knowledge and information | |
Improved co-ordination of care and patient flow | ‘We would call the emergency department if the patient was coming in just to let them know that a Covid + patient was coming in.’ – Interview 4 | Process | Engaging + Executing | |
THEME 3: Fragmentation of care | Navigating multiple systems | ‘[There was] a gap between us and the department [DHS] …we have no [ability to provide] clearance so the patient was still hanging on between us.’ – Interview 8 | Outer setting | External policy and incentives |
Disjointed care leading to delays and reduced quality of care | ‘People who were in isolation for a long time had secondary respiratory issues. From what I understood they [DHS] have a very binary metric or if you’re still symptomatic you’re going to stay in isolation….they wouldn’t then go and do anything about that in terms of ‘ok lets get one of our doctors to come out and assess you or get you back to ED and figure out what’s going on with you’. One patient had over 40 days of isolation. We had to fight for him.’ – interview 2 | Outer setting | External policy and incentives | |
Single point of contact for patients would improve care | ‘If it was to happen again I think each healthcare service should be responsible for their local area but there would need to be better co-ordination between health services.’ – Interview 2 | Outer setting | External policy and incentives | |
‘Thankyou for the daily phone calls to see how my husband was… but there were too many phone calls everyday from "everyone"- Patient survey respondent 23 | ||||
THEME 4:Workforce strengths | Mix of disciplines | ‘The ED and ICU guys understand that acute medical deterioration, but then people like physios and other allied health who work in the community understand the broader contextual needs from a social wellbeing point of view or access.’—Interview 2 | Inner setting | Implementation climate |
Meaningful work | ‘I think it goes to that idea of people having meaningful work, and I am important’ – Interview 4 | Inner setting | Implementation climate | |
Peer support | ‘Initially I was very hesitant to work here because I’ve worked in ED for almost 10 years and I hate change but because ED is not safe for me at the moment, I was offered… I mean they wanted me to get redeployed in this job and initially I thought oh my god, I don’t know I can do it. From day one they have been welcoming and I didn’t get intimidated at all because my suggestions were always welcome, they would always listen and stuff so yeah I’m just…I’m thankful that I have been redeployed here.’ – Interview 7 | Inner setting | Learning climate |
Theme 1: service implementation enablers and challenges
Inner setting: leadership engagement
Inner setting: relative priority
Inner setting: available resources
Inner setting: readiness for implementation/ process: planning
Outer setting: patient needs & resources/ inner setting network and communications, available resources and access to knowledge and information
Intervention characteristics: adaptability
Theme 2: service delivery benefits for patient
Characteristics of individuals: knowledge and beliefs about the intervention
Characteristics of individuals: self-efficacy, other personal attributes and access to knowledge and information
Process: Engaging and executing
Theme 3: fragmentation of care
Outer setting: external policy and incentives
Theme 4: workforce strengths
Inner setting: implementation climate
Inner setting: learning climate
Patient experience
Type of contact | No. of responses (%) |
---|---|
Daily phone call | 107 (39) |
Phone call every second day | 67 (25) |
Mix of phone calls and texts | 53 (20) |
Text messages only | 20 (7) |
Did not respond to this question | 24 (9) |
Content analysis | n | % | Cohen's Kappa first round coding |
---|---|---|---|
Responses to 'Can you given an example of advice you received that you found helpful?' n = 230 | |||
General advice was helpful about COVID-19 | 18 | 8% | 0.74 |
Advice on how to monitor my health | 17 | 7% | 0.5 |
Advice on how to reduce household transmission | 7 | 3% | 0.81 |
Advice on how to isolate at home | 23 | 10% | 0.84 |
Advice and provision of PPE | 11 | 5% | 0.87 |
Advice on how to access to essential supplies | 8 | 3% | 0.89 |
Advice on how to manage my symptoms | 8 | 3% | 0.72 |
Responses to 'Are there any additional comments about your experience with the community monitoring service that you would like to share?' n = 186 | |||
Service was easy to contact / access | 10 | 5% | 0.43 |
Service made too many calls to me | 3 | 2% | 0.66 |
Service was able to answer my questions | 16 | 9% | 0.81 |
Service identified deterioration and helped me | 10 | 5% | 0.86 |
Too much duplication between providers | 13 | 7% | 0.33a |
Service provided me with mental health support | 10 | 5% | 0.68 |
Introduction of SMS option was good | 5 | 3% | 0.83 |
Regular phone calls were helpful | 36 | 19% | 0.68 |
Felt supported by the service | 56 | 30% | 0.49 |
Grateful to have someone to talk to | 4 | 2% | 0.56 |
Welfare check important/ felt cared for | 11 | 6% | 0.52 |
Service facilitated clearance | 4 | 2% | 0.33a |