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In the United States, the COVID-19 pandemic accelerated the adoption of telehealth in home health care (HHC), but its sustainability remains uncertain. Despite telehealth's potential benefits, including improved patient monitoring and expanded access, the lack of reimbursement and regulatory constraints may limit widespread adoption. Understanding how home health agencies (HHAs) perceive these challenges is critical for shaping future telehealth policy. To examine HHA stakeholders' perspectives on the adoption, implementation, and sustainability of telehealth in the postpandemic era, with particular attention to operational benefits, financial and regulatory barriers, and the impact of new Centers for Medicare & Medicaid Services (CMS) billing codes (G-codes) for telehealth documentation. Qualitative study using semistructured interviews conducted between February and December 2024. The study followed the Practical Implementation Sustainability Model (PRISM) framework for data collection and analysis. Participants were recruited from HHAs and home health policy organizations across the United States, representing a range of agency types and geographic regions. A purposive and snowball sampling strategy was used to recruit 14 stakeholders, including HHA leaders, HHC clinicians, and policy experts. Interviews were transcribed and analyzed thematically using both deductive codes from the PRISM framework and inductive codes to capture emergent themes. Participants described their experiences with telehealth in HHC, including its operational feasibility, clinical utility, financial impact, and response to new CMS G-codes introduced in July 2023 for telehealth documentation. Primary topics of focus included stakeholders' perceptions of telehealth's benefits, barriers, and future viability in HHC. Stakeholders identified 4 key themes: (1) telehealth offers operational efficiencies (eg, increased patient touchpoints and workforce support) and clinical benefits (eg, improved patient monitoring and potential reduction in rehospitalizations); (2) the lack of CMS reimbursement makes telehealth adoption financially unsustainable for many HHAs; (3) specific HHAs, particularly those integrated with health systems or serving high-risk patient populations, may derive sufficient benefits to continue telehealth use despite financial constraints; and (4) current regulatory policies, including new CMS G-codes, increase administrative burden without providing financial incentives and discouraging telehealth adoption. While stakeholders recognize the benefits of telehealth in HHC, financial and regulatory challenges pose substantial barriers to its sustainability. Policymakers must weigh the advantages of telehealth reimbursement and regulatory support against concerns about wasteful care.

European health care systems face mounting pressures from an aging population, workforce shortages, and decentralization, challenging the delivery of accessible, high-quality care. eHealth solutions are widely promoted to enhance efficiency and improve the quality of care. Despite a strong policy report, anticipated benefits remain unrealized, as implementation processes often encounter barriers and high failure rates. Research shows that drivers and barriers are dynamic and shaped by actor interactions. Some studies suggest that certain actors, often acting as bricoleurs, play a critical role in overcoming these barriers through adaptive and improvised practices. However, little is known about how these actors enact roles, what features enable bricolage, and how structural conditions influence these practices. The aim of this study is twofold. First, it investigates the roles and features of actors involved in innovation processes, with a particular emphasis on the application of bricolage to overcome barriers and the influence of structural factors on these processes. Second, it aims to contribute both theoretical and empirical insights to deepen the understanding of barrier dynamics within innovation processes. We conducted a multiple-case study comprising 10 semistructured interviews, 11 focus groups with health care professionals, managers, trainers, and policymakers, participant observations of training sessions, and document analysis. An iterative process integrated the dramaturgical approach with the concept of bricolage, guiding the reflexive thematic analyses. Roles were enacted based on available information, context, and assigned functions. Service specialists (eg, superusers) and mediators (eg, unit or project managers) gained backstage insights through shadowing staff, evaluations, and support activities. When mandated and equipped with contextual and technical knowledge, these actors became bricoleurs, addressing unforeseen challenges by creatively mobilizing resources and thereby transforming barriers into promoters. Effective bricolage required proximity to the implementation site, dedicated involvement, and experiential knowledge of health care and technical domains. Key drivers included colocation, supportive management, stable teams, superusers, tailored training, follow-up activities, and informal evaluations. Barriers such as organizational silos, leadership shifts, staffing shortages, high turnover, geographic dispersion, and technology perceived as challenging or surveillance-oriented constrained bricolage and hindered implementation. Actors may become bricoleurs when their assigned roles, contextual knowledge, and backstage access enable them to improvise in response to unforeseen challenges. Through a dramaturgical lens, bricolage is an adaptive performance that sustains frontstage care delivery. Bricoleurs combine proximity, experiential knowledge, and dual expertise to transform barriers into drivers by adjusting the innovation process and fostering interaction. These practices illustrate the mutual shaping of structure and agency: enabling conditions expand the space for bricolage, while barriers narrow it. Understanding this dynamic is essential for advancing theory on innovation processes and for designing implementation strategies that leverage bricolage as a mechanism for transforming barriers into drivers of innovation.

Since their introduction with the Digital Care Act in 2019, selected digital health apps (DiGA) have been a part of the German statutory health care system. In order to become a DiGA, digital health apps have to complete a certification process covering both technical and evidence-related aspects. After completion, DiGA are added to the DiGA directory, containing a list of all reimbursable DiGA within German statutory health insurance. The first apps were added at the end of 2020, with the number steadily increasing. The novelty of this digital health care service and the fast implementation led to problems and barriers to optimal use along the way, which are studied from different stakeholder perspectives in this paper. The aim of this survey was to identify problems and barriers in the context of the admission, financing, and service provision of DiGA in the statutory health care system in Germany. We used semistructured expert interviews to evaluate the perspective of stakeholders of the German health care system on DiGA. The interview guide was developed according to Helfferich. The interviews were transcribed and analyzed using the qualitative content approach by Mayring, with the adjustments by Kuckartz. We conducted web-based interviews with stakeholders between February and June 2022. The stakeholder collective consisted of DiGA, statutory health insurance, physician, patient, technological, and quality assurance representatives. To identify problems from stakeholder perspectives regarding the admission, financing, and service distribution of DiGA, 21 interviews were conducted. The interviewed stakeholders reported problems with the authorization of DiGA and the corresponding process, for example, the duration of the DiGA Fast Track process. DiGA prices and the different negotiation positions were criticized, and financial challenges for smaller DiGA manufacturers were noted. Another problem was seen in the reimbursement of DiGA, independent of actual use by the patients. Within service provision, the participants reported superordinate aspects, for example, the negative public perception of DiGA and negative statements from stakeholders. In relation to the direct care process, technical problems (eg, with activation codes or software surrounding DiGA prescription) and insufficient knowledge and skills on the side of the patients, as well as the medical providers, were mentioned. Digital health apps have the potential to improve health care by addressing health problems in new, innovative ways. Since the evidence-based and regulated use of this technology is relatively new, problems and barriers limiting the optimized, patient-centered use arose throughout the first years. This study provides an overview of problems and barriers in the context of DiGA in Germany from different stakeholder perspectives. Nevertheless, with these problems being continuously addressed, digital health apps are trending toward becoming a contributing factor to health care in Germany. Since other countries showed interest in implementing a federally regulated approach similar to Germany, valuable implications can be drawn from this survey.

There is evidence that virtual delivery of early psychosis intervention (EPI) is well received by youth and has benefits such as reported improvements in accessibility, convenience, and comfort; however, potential barriers remain, including the digital divide and privacy concerns. Although initial engagement in EPI services is important for long-term recovery, little is known about initial engagement in the context of virtual care and the role of health equity and service use factors. This study aimed to identify factors associated with attendance at the initial EPI consultation appointment when most were being delivered virtually. This retrospective cohort study used electronic medical record data from patients aged 16 to 29 years who were referred to a large EPI program. The EPI program received 301 unique referrals that met study eligibility criteria from April to December 2020. Self-reported demographic variables were derived from the Centre for Addiction and Mental Health's structured health equity form and included age, gender, racial and ethnic group, country of birth, and sexual orientation. Service use factors derived from clinical documentation included referral source, days to consultation, and attendance at the consultation appointment, which was the primary outcome. Comparisons were made with 2018 to 2019 data from 999 participants from the same site prior to virtual care implementation using chi-square tests for categorical variables, independent t tests for continuous variables, and binary logistic regression. Patients had a mean age of 23.2 (SD 3.3) years, and 214 (71.1%) participants identified as male. Compared with pre-virtual care, there were significantly higher rates of inpatient referral (114/301, 37.9%) and lower rates of referral from outpatient and other providers (122/301, 40.5%) post-virtual care (χ22=18.7, P<.001), with a small effect size and moderately narrow CI (Cramér V=0.120, 95% CI 0.06 to 0.17). Following univariable tests and stepwise backward selection, identifying as Black (odds ratio 0.45, 95% CI 0.21 to 0.97) and being referred from the emergency department or bridging clinic (odds ratio 0.24, 95% CI 0.08 to 0.72) were associated with decreased odds of attendance at the consultation appointment in the final adjusted model. All tests were 2-sided with an α level of .05. This study is innovative in that it examines the self-reported health equity and service use factors that may contribute to nonattendance when most EPI appointments are delivered virtually, unlike previous studies that focused solely on differences in attendance rates. Although it was during the COVID-19 pandemic and may not be representative of virtual care in real-world practice, this study suggests that virtual care may improve initial engagement in EPI services; however, barriers to care still exist for Black patients and those referred from the emergency department. A hybrid model may improve connection to EPI, though targeted approaches are needed to bridge the digital divide and ensure that structurally marginalized and high-acuity patients have equitable access to care.

Evaluating implementation of digital health interventions (DHIs) in practice settings is complex, involving diverse users and multistep processes. Proactive planning can ensure implementation determinants and outcomes are captured for hybrid studies, but operational guidance for designing or planning hybrid DHI studies is limited. This study aimed to proactively define, prioritize, and operationalize measurement of implementation outcomes and determinants for a DHI hybrid effectiveness-implementation trial. We describe unique advantages and limitations of planning the trial implementation evaluation among a large-scale cohort study population and share results of a pretrial organizational readiness assessment. We planned a cluster-randomized, type II hybrid effectiveness-implementation trial testing PositiveLinks, a smartphone app for HIV care, compared to usual care (n=6 sites per arm), among HIV outpatient sites in the DC Cohort Longitudinal HIV Study in Washington, DC. We (1) defined components of the DHI and associated implementation strategy; (2) selected implementation science frameworks to accomplish evaluation aims; (3) mapped framework dimensions, domains, and constructs to implementation strategy steps; (4) modified or created instruments to collect data for implementation outcome measures and determinants; and (5) developed a compatible implementation science data collection and management plan. Provider baseline surveys administered at intervention sites probed usage of digital tools and assessed provider readiness for implementation with the Organizational Readiness to Implement Change tool. We specified DHI and implementation strategy toward planning measurement of DHI and broader program reach and adoption. Mapping of implementation strategy steps to the Reach Effectiveness Adoption Implementation Maintenance framework prompted considerations for how to capture understudied aspects of each dimension: denominators and demographic representativeness within reach or adoption, and provider or organization-level adaptations, dose, and fidelity within the implementation dimension. Our process also prompted the creation of tools to obtain detailed determinants across domains and constructs of the Consolidated Framework for Implementation Research within a large sample at multiple time points. Some aspects of real-world PositiveLinks implementation were not reflected within the planned hybrid trial (eg, research assistants selected as de facto site implementation leads) or were modified to preserve internal validity of effectiveness measurement (eg, \"Community of Practice\"). Providers and research assistants (n=17) at intervention sites self-reported high baseline use of digital tools to communicate with patients. Readiness assessment revealed high median (48, IQR 45-54) total Organizational Readiness to Implement Change scores, with research assistants scoring higher than physicians (52.5, IQR 44-55 vs 48.0, IQR 46-49). Key takeaways, challenges, and opportunities arose in planning the implementation evaluation within a hybrid DHI trial among a cohort population. Prospective trial planning must balance generalizability of implementation processes to \"real world\" conditions with rigorous procedures to measure intervention effectiveness. Rapid, scalable tools require further study to enable evaluations within large multisite hybrid studies.

Counseling in family dementia care aims to support caregivers in mastering challenges. The use of information and communication technologies (ICT) to administer counseling can improve accessibility. Evidence syntheses report inconsistent findings on the effectiveness of technology-assisted counseling. There is a considerable heterogeneity in outcomes assessed in clinical trials, and approaches to develop and evaluate interventions are not guided by theory in most cases. This study aims to develop an initial program theory of a technology-assisted counseling intervention for family dementia caregivers and to create the data basis for the consensus process of a core outcome set. We integrated the methodological strands for the development of a program theory and a core outcome set in an innovative way. A scoping review was conducted to collect data on characteristics and theoretical foundations of technology-mediated counseling interventions as well as outcomes of clinical studies. We explored the lived experience of relevant interest-holders and conducted semistructured interviews applying a phenomenological approach to data analysis. Synthesis of findings was performed by developing a logic model and formulating an initial program theory. We included 69 records reporting on 34 interventions. Designs and other study characteristics vary, and interventions are heterogeneous in terms of components and ICT used for delivering counseling. We conducted interviews with 15 family caregivers and 12 counselors. The themes being affected, feeling insecure and helpless in the face of the health care system, and search for information and communicative exchange illustrate the caregivers' lifeworld perception. Themes identified in counselors' interviews comprise work attitude and standards, unpredictability, expectations, working conditions, organizational influence, and tools: techniques and networking. The constitutive pattern of having/being somebody to count on was incorporated into the program theory. In the theory of change, we describe the way to a sustainable supportive cooperation between caregivers and counselors ensuring ongoing support throughout the caregiving process. We explicate the effects of the technology-assisted counseling intervention such as improved knowledge, attitude, and interaction, as well as stability and safety of care in the outcomes chain. The theory of action comprises the inputs, activities, and outputs of the intervention. The graphical synthesis of findings is presented in the logic model. To effectively develop, implement, and evaluate technology-assisted counseling in family dementia care, a theory-led approach is essential. A carefully modeled intervention that combines technological options with in-person counseling may help to overcome disparities in access to health care and improve accessibility to counseling. A supportive working environment for counselors, in which artificial intelligence is used to reduce time spent on documentation and administrative tasks, may help mitigate the effects of the growing shortage of skilled professionals.

Virtual health care models that incorporate registered nurse triage with rapid access to same-day virtual visits with clinicians represent a growing innovation in health care delivery. While traditional telephone advice lines focus primarily on registered nurse-led triage and care navigation, systems such as the Department of Veterans Affairs (VA) are beginning to embed physicians and advanced practice providers directly into these platforms. This hybrid model has the potential to enhance clinical responsiveness, reduce unnecessary emergency department and urgent care visits, and increase patient satisfaction by providing timely care from home. This study aimed to explore Veterans' experiences and perceptions of the VA's integrated virtual triage and urgent care model, specifically through the VA Health Connect platform. We sought to understand how Veterans learned about and interacted with these services and to gather their insights on aspects to preserve or improve. We conducted in-depth qualitative interviews with 24 Veterans from various geographical regions served by 6 VA health care systems. Interviews were carried out between June 18 and August 8, 2024. Data were analyzed using a qualitative descriptive approach with constant comparison to identify emergent themes and representative quotes. Participants reported high satisfaction with VA Health Connect's nurse triage and virtual clinical visit services. Key benefits included timeliness of care, personal time savings, efficient service organization, and positive interactions with nurses and providers. Veterans appreciated the convenience of resolving health issues quickly and remotely, often citing significant travel burdens avoided. They also highlighted the knowledgeable and personalized clinical advice received. However, several areas for improvement were identified. Some Veterans expressed frustration about being routed to nurse triage instead of directly scheduling with their primary care providers. Moreover, many were initially unaware of the full range of services available through VA Health Connect and suggested enhanced outreach and communication strategies. Veterans are highly satisfied with the VA Health Connect model, valuing its timeliness, convenience, and the professionalism of clinical staff. Effective promotion and clear communication about the capabilities and limitations of the service could further enhance user experience and uptake. As this integrated care model continues to evolve, its success will depend on effectively integrating virtual services into routine care and ensuring Veterans are well-informed and confident in using these resources.

Community health screening programs frequently report inconsistent follow-up rates and barriers to sustained lifestyle changes. HealthStart is a Self-Determination Theory (SDT)-based intervention that aims to increase the autonomy and competence of participants via volunteer engagement, health and digital coaching, and posthealth screening follow-up. Youth community health volunteers (YCHVs) were taught principles of motivational interviewing, health coaching, and the social determinants of health through a program model anchored in principles of intergenerational and service learning. YCHVs, guided by health care volunteers, served as health and digital advocates for participants over a 3-month postscreening period. This study aims to evaluate the effectiveness and acceptability of the HealthStart program, a structured, layperson-led intergenerational health coaching intervention. This study used a convergent parallel mixed methods design. A total of 192 older adult participants' (mean age 66.9, SD 9.6 years) quantitative data were collected through pre- and postprogram surveys between September 2022 and January 2024. Follow-up with primary care provider (PCP) was the primary outcome; secondary outcomes include health goal attainment, self-efficacy, and digital and health literacy among older adults, and acceptability among all stakeholders. PCP follow-up and health goal attainment were self-reported, while self-efficacy was measured using the Patient Activation Measure-13. Health and digital literacy were assessed with an adapted questionnaire and the eHealth Literacy Scale (eHEALS), respectively. A total of 36 semistructured interviews were conducted with 13 older adults, 17 YCHVs, and 6 health care volunteers in the qualitative study between November 2023 and January 2024, which were qualitatively analyzed using thematic analysis. A joint analysis was conducted to generate meta-inferences. The follow-up rate among PCPs increased significantly from 42.7% to 84.5% (P<.001). A total of 66.2% (92/139) of the participants achieved their health goals, and 81.3% (113/139) reported satisfaction with the program. There were no significant pre-post differences in Patient Activation Measure-13, knowledge, and eHEALS scores. However, a statistically significant correlation was found between postcycle eHEALS scores and the number of follow-up visits (P=.003). The qualitative findings substantiate HealthStart's Theory of Change and its SDT underpinnings. Participants' narratives highlighted the 3 SDT psychological needs, increased autonomy, competence, and relatedness, which are associated with sustained behavior change and health engagement. An increase in the PCP follow-up rate was influenced by individually tailored goal setting and relationship-building that leveraged motivational interviewing to support intrinsic motivation. The program's primary outcome was, to some extent, influenced by digital health onboarding and possibly improvements in health literacy. Participants' self-efficacy could have been enhanced with a structured social prescription framework. HealthStart demonstrated the feasibility of using YCHVs and SDT principles to improve PCP follow-up rates and promote healthier lifestyles through digital enablement among older adults participating in community health screening.