Health equity related challenges and experiences during the rapid implementation of virtual care during COVID-19: a multiple case study.

BACKGROUND: Virtual care quickly became of crucial importance to health systems around the world during the COVID-19 pandemic. Despite the potential of virtual care to enhance access for some communities, the scale and pace at which services were virtualized did not leave many organizations with sufficient time and resources to ensure optimal and equitable delivery of care for everyone. The objective of this paper is to outline the experiences of health care organizations rapidly implementing virtual care during the first wave of the COVID-19 pandemic and examine whether and how health equity was considered. METHODS: We used an exploratory, multiple case study approach involving four health and social service organizations providing virtual care services to structurally marginalized communities in the province of Ontario, Canada. We conducted semi-structured qualitative interviews with providers, managers, and patients to understand the challenges experienced by organizations and the strategies put in place to support health equity during the rapid virtualization of care. Thirty-eight interviews were thematically analyzed using rapid analytic techniques. RESULTS: Organizations experienced challenges related to infrastructure availability, digital health literacy, culturally appropriate approaches, capacity for health equity, and virtual care suitability. Strategies to support health equity included the provision of blended models of care, creation of volunteer and staff support teams, participation in community engagement and outreach, and securement of infrastructure for clients. We put our findings into the context of an existing framework conceptualizing access to health care and expand on what this means for equitable access to virtual care for structurally marginalized communities. CONCLUSION: This paper highlights the need to pay greater attention to the role of health equity in virtual care delivery and situate that conversation around existing inequitable structures in the health care system that are perpetuated when delivering care virtually. An equitable and sustainable approach to virtual care delivery will require applying an intersectionality lens on the strategies and solutions needed to address existing inequities in the system.

Equity Promoting Integrated Care: Definition and Future Development.

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems.

Challenges and strategies for promoting health equity in virtual care: findings and policy directions from a scoping review of reviews.

OBJECTIVE: We sought to understand and synthesize review-level evidence on the challenges associated with accessibility of virtual care among underserved population groups and to identify strategies that can improve access to, uptake of, and engagement with virtual care for these populations. MATERIALS AND METHODS: A scoping review of reviews was conducted (protocol available at doi: 10.2196/22847). A total of 14 028 records were retrieved from MEDLINE, EMBASE, CINAHL, Scopus, and Epistemonikos databases. Data were abstracted, and challenges and strategies were identified and summarized for each underserved population group and across population groups. RESULTS: A total of 37 reviews were included. Commonly occurring challenges and strategies were grouped into 6 key thematic areas based on similarities across communities: (1) the person's orientation toward health-related needs, (2) the person's orientation toward health-related technology, (3) the person's digital literacy, (4) technology design, (5) health system structure and organization, and (6) social and structural determinants of access to technology-enabled care. We suggest 4 important directions for policy development: (1) investment in digital health literacy education and training, (2) inclusive digital health technology design, (3) incentivizing inclusive digital health care, and (4) investment in affordable and accessible infrastructure. DISCUSSION AND CONCLUSION: Challenges associated with accessibility of virtual care among underserved population groups can occur at the individual, technological, health system, and social/structural determinant levels. Although the policy approaches suggested by our review are likely to be difficult to achieve in a given policy context, they are essential to a more equitable future for virtual care.

Innovative Policy Supports For Integrated Health And Social Care Programs In High-Income Countries.

As high-income countries face the challenge of providing better and more efficient integrated health and social care to high-needs and high-cost populations, they may require innovative policy supports at both the national and local levels. We categorized policy supports into four areas: governance and partnerships; workforce and staffing; financing and payment; and data sharing and use. Our structured survey of thirty integrated health and social care programs in high-income countries in 2018 found that the majority of programs had policy supports in two or more areas, with supports for governance and partnerships and for workforce and staffing being the most common. Financing and payment and data sharing and use were less common. Local partnerships empowered integration across sectors, and new staff roles that spanned health and social care embedded this integration in care delivery. National policies-including bundled financing and investment in data-enabled integration and cross-sector accountability.

Innovative Integrated Health And Social Care Programs In Eleven High-Income Countries.

High-income countries face the challenge of providing effective and efficient care to the relatively small proportion of their populations with high health and social care needs. Recent reports suggest that integrated health and social care programs target specific high-needs population segments, coordinate health and social care services to meet their clients' needs, and engage clients and their caregivers. We identified thirty health and social care programs in eleven high-income countries that delivered care in new ways. We used a structured survey to characterize the strategies and activities used by these programs to identify and recruit clients, coordinate care, and engage clients and caregivers. We found that there were some common features in the implementation of these innovations across the eleven countries and some variation related to local context or the clients served by these programs. Researchers could use this structured approach to better characterize the core components of innovative integrated care programs. Policy makers could use this approach to provide a common language for international policy exchange, and this structured characterization of successful programs could play an important role in spreading them and scaling them up.

Challenges and Strategies for Promoting Health Equity in Virtual Care: Protocol for a Scoping Review of Reviews.

BACKGROUND: The rapid virtualization of health services during the COVID-19 pandemic has drawn increasing attention to the impact of virtual care technologies on health equity. In some circumstances, virtual care initiatives have been shown to increase health disparities, as individuals from underserved communities are less likely to benefit from such initiatives. OBJECTIVE: The purpose of this paper is to describe a protocol for a scoping review of reviews that aims to map review-level evidence that describes challenges and strategies for promoting effective engagement with virtual care technologies among underserved communities. METHODS: Our methodology was adapted from seminal scoping review guidelines provided by Arksey and O'Malley, Levac at al, Colquhoun et al, and the Joanna Briggs Institute. Our search strategy was developed for the following databases: MEDLINE (on Ovid), EMBASE (on Ovid), CINAHL (on EBSCO), Scopus, and Epistemonikos. Supplementary searches will include the use of Google Scholar and reference tracking. Each citation will be independently screened by 2 researchers at the title and abstract level, and full-text screening will be performed in accordance with our eligibility criteria. The eligibility criteria focused on the inclusion of methods-driven reviews (ie, systematic reviews, scoping reviews, meta-analyses, realist reviews, and critical interpretative syntheses) to enhance rigor and quality. Other inclusion criteria included a focus on virtual care services that facilitate bidirectional patient-provider communication (ie, video, telephone, and asynchronous messaging visits) for underserved populations (ie, those who experience social disadvantage due to race, age, income, and other factors related to the social determinants of health). RESULTS: This scoping review of reviews will provide a broad overview of identified challenges associated with the accessibility of virtual health care services among underserved communities. In addition, strategies for improving the access to, uptake of, and engagement with virtual care technologies among underserved communities will be identified. The knowledge synthesized from this review will aid in developing and implementing virtual services that acknowledge the unique needs of populations who experience barriers to care and disproportionately worse health outcomes. The results will also inform gaps in current research. CONCLUSIONS: The rapid shift toward virtual health services has highlighted the urgent need to critically examine the intersection of virtual care and health equity. Although technology-driven innovations in health care generally aim to improve access, quality, and health outcomes, it is also possible for these innovations to produce intervention-generated inequities. Assessing current review-level evidence on the key challenges and strategies for improving the application of virtual care in underserved communities is imperative for ensuring that virtual care benefits all populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/22847.