All fifteen staff in the program participated in the interviews (Table 3). Four of these staff were responsible for development, implementation, and management of the service, four staff were involved in both the development and implementation as well as provision of service, while the remaining seven staff were part of the direct care team involved only in provision of service. Interviews were conducted from 15th of September to 29th of November 2020 and were between 17 and 55 minutes in duration.
Across the 15 interviews, thematic saturation was reached. A total of four final themes, with 19 subthemes emerged, and these sub themes aligned with 18 CFIR constructs. Table 4 provides an overview of each of the final themes, CFIR constructs and supporting quotes. These themes are discussed further below.
Theme 1: Service commissioning enablers and challenges
INNER SETTING: Leadership engagement
Leadership engagement was essential to the success of this program, all the way from the hospital executive to the leadership within the team itself. The senior executive leadership team at NH requested a community monitoring service be implemented within a week. To help facilitate this rapid establishment, key implementation tasks were divided up across four senior personnel within the team, referred to in the interviews as the ‘command centre’. This ‘command centre’ division of labour was allocated across the following: workforce, telecommunication, patient management systems and policies and procedures. Telephone systems were set up in a call centre style with one central phone number that enrolled patients could ring to access support. Patient management systems were established to track patients and ensure reporting capability.
INNER SETTING: Relative priority
The potential risks to both the individual (management of deterioration) and the community (spread of infection) created a sense of urgency and the service was given high priority within the organisation. The DoH provided a specific funding stream to the health service to support establishment of the service.
INNER SETTING: Available resources
One of the key success factors for rapid implementation was being able to draw on existing staff as a resource. Frontline healthcare staff with pre-existing medical conditions who had been furloughed due to exposure risk, were approached and redeployed into the direct care team.
INNER SETTING: Readiness for implementation/ PROCESS: Planning
While the program benefited from being able to engage furloughed staff and quickly induct them into the program, the rapid implementation requirements meant that initial staffing levels were still not adequate to meet the demands of the program. Staff engaged early reported feeling overwhelmed by the volume of patients. Those responsible for training new staff reported feeling frustrated by having been removed from monitoring patients to onboard new staff in at sporadic and irregular intervals. The program would have benefited from more time to forward plan, and onboarding staff in a consistent manner.
OUTER SETTING: Patient needs & Resources/ INNER SETTING Network and communications, Available resources and Access to knowledge and information
Once again, this program benefited from access to existing resources, this time in the form of written resources, and was able to utilise a policy procedure that had been developed by another hospital as a basis for the program and adapted it for use locally. Telephone scripts were developed to ensure consistency of approach, and SMS links to trustworthy information about important aspects of self-care, including identification of deterioration, were created that could be sent through to patients.
INTERVENTION CHARACTERISTICS: Adaptability
The first four weeks were crucial to the success of the service, with staff having to apply a dynamic and flexible approach to manage constant change, reorganisation, and progress over time. During these first weeks, the service adapted in response to feedback from patients and staff working in the program, with additional features added. This included text messages as an alternative to telephone calls for those at low risk of developing complications.
Theme 2: Service delivery benefits for patient
CHARACTERISTICS OF INDIVIDUALS: Knowledge and beliefs about the intervention
In all 15 interviews, the main reported strength of the service was its ability to adapt to provide personalised support and education for patients. This allowed staff to build rapport and trust. In some cases, staff reported that this was what made all the difference when it came to convincing a patient that they required an ambulance review or hospital attendance.
CHARACTERISTICS OF INDIVIDUALS: Self-efficacy, Other personal attributes and Access to knowledge and information
Staff reported that initially they were tasked with symptom and welfare checking, with the primary aim of early detection of deterioration. However, it quickly became evident that an information vacuum existed and that many enrolled patients were struggling to find information about how to safely manage COVID-19 in the home. Staff reported that they regularly responded to questions about how to safely isolate one family member within a large household, including how to manage used crockery and cutlery, shared bathrooms and interaction within the home (for example, wearing masks when talking to family members through an open door, even when socially distanced). Having access to interpreters to assist with translating information for patients from migrant backgrounds was essential, and staff often had to provide clarification of misinformation in other languages. Overall, staff reported that supporting large households to understand isolation requirements played a crucial role in reducing community transmission of the virus.
PROCESS: Engaging and executing
One of the reported benefits of running a community monitoring program within the hospital setting was the ability for improved co-ordination of care. When staff identified that a patient was deteriorating and required a hospital attendance, they were able to contact the emergency department to provide a handover. Staff also had ready access to infectious disease specialists as other important specialists for high risk patients (e.g., obstetricians). Patient management and clinical systems were also linked, so medical staff managing deterioration had access to information about the patients’ health over the preceding days.
Theme 3: Fragmentation of care
OUTER SETTING: External policy and incentives
Consistently reported across all interviews, the greatest challenge experienced by staff was the fragmentation of services and division of roles between the hospital network (NH) and the centralised DoH. Staff reported that patients (and sometimes even the staff themselves) struggled to understand the difference between the work being carried out by the two agencies, or to recognise who was contacting them, and some reported that they felt burdened by the number of contacts they received.
The DoH also monitored patients’ symptoms with the purpose of assessing their COVID-19 status and for providing clearance for them to return to normal activities. NH were unable to provide this clearance for patients, however, staff were able to act in an advocacy role when patients failed to meet the criteria for clearance.
Finally, a number of staff also reported that duplication of care could also occur across health services, with a number of health services potentially being involved with a single household, depending on the test site for individual members. Staff reported that a regional approach to provision of monitoring services would be an improvement if similar services were operationalised in the future.
Theme 4: Workforce strengths
INNER SETTING: Implementation climate
Rapid implementation of this service was made possible by the ready access to experienced and knowledgeable clinically qualified staff who had been furloughed from other active clinical roles within the health service. These staff brought a variety of skills and abilities and complemented one another. The staff mix included medical (respiratory physician), allied health (physiotherapy and exercise physiology) and nursing (paediatric, emergency and palliative care). Staff identified that this skill mix meant there was always someone in the team who could answer a question if another team member was uncertain.
The team reported a strong sense of pride about their ‘contribution to the war effort’. Working in the community monitoring service felt like a privilege when they were unable to work in their normal roles and still wanted to be able to contribute to the management of the pandemic.
INNER SETTING: Learning Climate
All staff that were interviewed reported they felt well supported by their peers in the service and by the leadership team, and that they were given opportunities to contribute to the direction of the service (including through improving the telephone scripts, and policies and procedures). None had ever delivered services in this manner and this meant they were a little nervous initially.
A total of 850 patients were enrolled in the service. Due to the speed of implementation, ethics approval was gained after the service had already been implemented and patients enrolled. Therefore, only those who were enrolled following ethics approval and who responded to a post discharge phone call (n = 646) were eligible to participate. No demographic information was collected as part of this data collection, however demographics for all service users are available in a previous publication (12). Data was collected from the 12th of September to the 9th of November 2020.
Most participants who responded to the survey received phone calls either daily or second daily (Table 5). 271 patients participated in the survey (response rate 42%). Overall, surveyed patients were highly satisfied with the care they received (Fig. 2). 96% of surveyed patients felt the service was helpful (n = 261, agree and strongly agree response options), 92% felt that they were able to get the help they needed from the service (n = 250), 98% felt supported to understand how to isolate at home (n = 266) and 97% felt supported to manage their symptoms (n = 263). In response to the question would you recommend the service to a friend or family member if they had COVID, 236 (87%) of respondents said that they would.
The two open ended questions were coded across 19 predefined themes. These themes, the number of respondents and the inter-tester reliability for the initial coding and re-coding are provided in Table 6. Only two themes had a poor level of agreement (below 0.41) and were recoded. When discussed, 100% agreement was reached.
Thirty-one patients chose not to respond to the question on examples of advice and 77 had no comments to provide about the service. The most frequently reported example of advice received was on how to isolate at home (n = 23, 12%). The most common open-ended response about experience related to feeling supported by the service (n = 56, 30%).
A small number of patient participants (n = 13) supported the findings from staff interviews when they identified frustrations associated with fragmentation of care between DoH and the NH service.
Ten (5%) respondents identified that the service recognised deterioriation quickly and managed the transition to hospital for which they were grateful, while a further four (2%) identified that the service facilitated clearance to return to normal activity for them. Overall, the service escalated 30 individuals (3.5% of all) for urgent medical care (12). These findings also support the findings from staff interviews. Additionally, responses initiated by patients demonstrated the importance of advice on how to safely isolate at home (n = 23) and how to reduce household transmission (n = 7) support the feedback from the staff interviews that this was a very important part of the service.