Subtheme 1a interprofessional communication.

Hospital providers explained that the pre-pandemic format of multidisciplinary rounds, used by the interprofessional healthcare team to collaboratively plan a patient’s discharge, was modified to adhere to physical distancing requirements. While these rounds occurred in-person prior to the pandemic, COVID-19 caused some units to conduct this using teleconferencing (i.e. a telephone call with more than two simultaneous participants). In contrast, others continued in person but were moved to a larger room to allow physical distancing. However, as P13 (hospital provider) described below, when rounds were conducted over teleconference, information tended to be more easily overlooked and less information was shared by the team.

"I would say daily rounds are not as productive as they were when we were all able to be in the same room. For a number of reasons. I think it’s just more difficult and challenging over teleconference. So, I think people are less likely to interrupt, or there are not so much miscommunications, but I think they take a little longer, number one. I think to be honest we glaze over things that we may have previously had gone over more because we find that rounds are more time-consuming doing them over teleconference."

Providers who participated in physically distanced in-person rounds reported communicating challenges with the team while wearing Personal Protective Equipment (PPE). Moreover, they did not have access to their usual visual planning tool due to moving to a different space. As a result of these changes, interprofessional communication around discharge planning was perceived as less productive during the pandemic.

In the community, P4, a community care coordinator who conducted hospital and home visits, and worked remotely prior to the pandemic, was less impacted by the shift to remote communication and care than those who were less accustomed to remote communication.

"One of the most interesting things when COVID hit, and everyone was sent home, so I’ve been doing this for 10 years already. So the next day, nothing changed for me. I work all over the place, you know? I joke I’m like a turtle, and I carry everything on my back. I can work wherever I am. So at the moment, I have been working more from home…From that perspective I think we were fairly technologically-advanced with laptops that had access to [Internet] and VPN. All of those things were very familiar for me which I don’t think were for others."

However, all community providers, including this care coordinator, felt that in-person interprofessional communication related to patient care was more comprehensive and productive. Additionally, due to technology being used more frequently to support remote communication, one community provider (P1) was concerned that communication with new medical residents regarding medical training was negatively impacted. For instance, P1 explained that it was much harder for residents to learn rapport-building skills and hone their observational assessment and diagnostic skills.

Subtheme 1b communication with patients.

During the pandemic, hospital providers continued to communicate with patients in-person but experienced challenges while wearing PPE due to a lack of non-verbal communication (e.g. facial expressions) and reduced speech volume. As a result, communicating with patients took longer and increased the risk of misinterpretation than communication in the pre-pandemic context.

In contrast to hospital providers, most community providers interacted with patients over the phone as in-person visits were restricted to patients on a case-by-case basis. However, determining which patients required an in-person or remote visit simply based on verbal information shared by the patient or caregiver over the phone was challenging. Providers reported that patients preferred not to attend in-person appointments in some instances due to a fear of COVID-19 transmission from the healthcare institution. Concerning phone communication, providers were concerned that the lack of observational data increased the risk of misdiagnosis. Community providers indicated that phone interactions took much longer than in-person assessments as they were not trained or accustomed to assessing and diagnosing patients over the phone. Remote assessments took longer because providers had to ask patients or caregivers more questions to compensate for the lack of observational data.

Subtheme 1c communication with caregivers.

During the pandemic, both hospital and community providers communicated with caregivers primarily through phone or email more often than they did pre-pandemic. The type of information that was shared with or sought from caregivers differed between hospital and community providers. Hospital providers communicated with caregivers to obtain necessary historical information and provided information about discharge plans (e.g. a patient’s baseline or current health and function, medication and resources/support available after hospital discharge). Community providers communicated with the patient and caregiver remotely at the same time. Community providers addressed and managed patient and caregiver concerns or needs after hospital discharge. Both hospital and community providers agreed that remote communication enabled them to share the necessary information with caregivers. However, they were concerned that remote communication negatively impacted the provider-caregiver relationship and caused caregivers to mistrust the information given to them by providers.

"I think a lot of families, they get it but I do also hear from the families that you know because they haven’t seen their loved one, it’s hard for them to even though we as professionals are saying ’oh you know, for example, your dad needs help now. Someone will need to remind him to take his pills, you know? But they will go ’oh he was taking his pills by himself before’ or ’they didn’t need help going to the toilet before‴

(P10, hospital provider).

Subtheme 2a additional barriers to managing transitions from the hospital.

While hospital providers indicated that discharge processes were not overly different during the pandemic, they believed that discharge planning was "more complex" (P2, hospital provider) because there were additional discharge barriers to manage. The first barrier participants identified was that providers were uncertain about the availability of community resources and services and patient willingness to receive them. Providers explained that the availability of community resources and services had constantly changed during the pandemic. Hospital providers were uncertain about which community services they could refer patients to after discharge and were concerned that patients were falling through the cracks (i.e. not getting access to the community services they needed). P8 (a hospital provider) explained that this uncertainty was caused by less frequent communication between hospital and community organizations compared to pre-pandemic when fewer updates/communication between hospital and community staff about service availability was required because community services were more consistent. Another factor complicating discharge planning was that providers also had to consider alternative discharge supports and resources to recommend or refer patients because patients and caregivers were declining recommended community services due to a fear of COVID-19 transmission from community providers.

The second discharge barrier was that hospital providers found it harder to obtain the information they needed to plan discharges (e.g. patient’s baseline, resources available, etc.), mainly from patients who had language or communication difficulties. They explained that this information would be readily available from caregivers who were often at the patient’s bedside prior to the pandemic. P2 (a hospital provider) explained that they had to manage these additional discharge barriers while managing added pressure from the organization to quickly discharge patients as organizations attempted to create capacity to care for the overwhelming number of patients with COVID-19. Third, hospital providers explained that discharges were being delayed directly by COVID-19 in instances of an outbreak on the unit or if the patient’s household members had the virus.

"We are trying to get patients out of rehab as fast as possible…we are trying to offload patients from acute care so they are coming to us so that we are offloading from them, but we are also trying to get people home as fast as we can, safely. So that way we can keep taking people"

(P2, hospital provider).

Compounding this, providers explained that staffing shortages added to the stress and pressure they faced while facilitating transitions during the pandemic. They indicated that at the start of the pandemic, staffing shortages were caused by hospitals operating at overcapacity and sick calls from staff due to redeployment, illness or having to isolate after being exposed to the virus.

Subtheme 2b discharge service restrictions and delays in community care.

Similar to hospital providers, community providers were concerned about patients having restricted or delayed access to recommended community services, which were limited by community staff shortages or patients refusing these services. Additionally, community providers expressed concerns about discharge services delays as they believed unreasonable expectations were imposed on them. For instance, P16 (a community provider) explained that it was unrealistic for hospital providers to expect community providers to schedule in-person follow-ups with patients within seven days of hospital discharge during the pandemic because of the limited capacity to schedule in-person appointments. Moreover, if patients were infected with the COVID-19 virus, patients were temporarily ineligible to receive medical testing/imaging, which further delayed discharge services in the community.

Subtheme 2c additional work.

Hospital providers indicated that they had to take on additional tasks during the pandemic, which added to their existing overwhelming workload. For instance, prior to the pandemic, they explained discharge instructions to patients and caregivers simultaneously as both were present in person. However, during the pandemic, hospital providers indicated that they had to explain discharge instructions twice—once in-person to the patient and then again to caregivers over the phone or through email. Moreover, prior to the pandemic, providers were aware of which services were available; however, many services were temporarily closed or understaffed during the pandemic. As such, providers explained that they frequently contacted community organizations to confirm service availability during the pandemic. This additional work was perceived as problematic because it reduced time for direct patient care.

Similarly, community providers indicated that they were obliged to assume additional work during the pandemic. Due to patients being discharged from the hospital sooner than they would have been pre-pandemic, community providers explained that they had to care for patients who were sicker and required more medical intervention. Moreover, community providers indicated that patients and caregivers were contacting community providers more often with questions relating to their health and care while in the hospital. The increased communication with community providers resulted from caregivers having limited involvement in the patient’s hospital care compared to before the pandemic. Community providers felt limited in their responses, as they did not always have comprehensive details about the care provided in the hospital.

Subtheme 2d barriers to care provision.

Hospital providers found that conducting assessments with patients (a vital part of care provision) during the pandemic was challenging for multiple reasons relating to infection control measures. Due to infection control measures, providers were restricted from taking materials (e.g. cognitive assessments) into the hospital rooms. In addition, patients were restricted from using the hospital therapy gym during a mandatory seven-day isolation period after arriving on the unit or if they tested positive for the COVID-19 virus, limiting patients’ functional progression. Finally, hospital providers explained that planning discharge for patients with complex care needs was more difficult due to organizational policies and infection control measures restricting home visits.

Community providers explained that some policies implemented during the pandemic to reduce the risk of virus transmission impacted care provision. For instance, these new policies directed community providers to deliver care virtually while restricting in-person care. However, providers expressed concerns with virtual care, including increased risks of misdiagnosing due to the inability to perform physical assessments. Many providers felt that telephone-based assessments failed to provide them with a comprehensive understanding of the patient’s condition. Most providers considered virtual care inferior to in-person.

Subtheme 2e: Increased homecare support.

A hospital provider explained that some discharge concerns were alleviated with a new program designed to increase home support to a level that previously believed was impossible. The program aimed to support early discharges and create hospital capacity to manage the increased number of hospitalized patients. This program was beneficial in care transitions, allowing providers to discharge patients earlier as these new homecare programs could manage their care needs.

"We’ve seen different programs that are allowing the [de-identified homecare agency] to have different supports to do different programs that allow for patients to get out of the hospital with whatever means necessary, essentially. So being able to do enhanced programs or high-intensity supports at home. Like for rehab, physiotherapy and occupational therapy, being able to do home programs that allow patients to get out of the hospital with a higher level of support when maybe otherwise they wouldn’t be able to do that."

Subtheme 3a difficult for caregivers/families to accept changes in patient’s status.

Hospital providers perceived that caregivers and families had difficulty trusting and accepting information about changes to a patient’s baseline health and functional and physical status level because of restricted visitation. Restricted visitation was due to restricted visitor policies in the hospital and caregivers’ hesitancy to visit patients. Providers explained that caregivers might be unprepared to manage a patient’s care needs without a comprehensive understanding of a patient’s status after hospital discharge.

Subtheme 3b additional caregiver stress and burden.

Hospital and community providers explained that transitions home from the hospital were even more stressful for caregivers during the pandemic for multiple reasons. First, caregivers were required to take on additional care activities after a patient returned home from the hospital if they declined community services or the services were unavailable. Second, hospital providers perceived caregivers were less prepared to manage a patient’s care after hospital discharge because caregivers had fewer opportunities to be involved in discharge planning due to limited hospital visitations. Third, hospital providers indicated that caregiver education/training, an essential part of the discharge process, primarily occurred through email or phone during the pandemic. Although providers noted that communication by telephone was helpful in some cases (e.g. caregivers not having to wait at the hospital to speak to a clinician), this format was less comprehensive as it did not allow hands-on demonstrations of discharge instructions.

Subtheme 4a technology used to support transitions.

Hospital and community providers used technology for different purposes during the pandemic. Hospital providers used faxes, electronic referrals, phone calls, videoconferencing and emails to communicate with other healthcare providers in the same or different organizations and gather/share information with caregivers and family members (e.g. during family conferences). Also, hospital providers would sometimes use the same medium that the patient was already using to communicate with their caregiver or family member (e.g. Facetime, WhatsApp, etc.). To streamline information sharing, P3 (a hospital provider) indicated he would try to schedule his patient visits to coincide with a time that patients were already communicating with their caregiver or family member: "What I started to do, and I think this is actually an enhancement in care is that I would actually go to the bedside and phone the family member from the bedside with the patient present and I think that has been working out ok."

Community providers indicated using various technologies during the pandemic, including one-way email, phone calls or sometimes videoconferencing. These technologies were used to connect with patients, caregivers, and other providers to assess, diagnose, and exchange information. Providers indicated that they often used one-way emails and telephones to communicate with patients or caregivers. They agreed that these mediums allowed them to continue delivering care, but they highlighted several concerns which impact the post-pandemic sustainability of these technologies in routine care.

Subtheme 4b concerns about technology.

Hospital and community providers explained that they rarely used videoconferencing due to technical issues and concerns. Providers also assumed that older patients and caregivers might not be comfortable or have the resources and skills to use videoconference. Providers also indicated that a lack of comfort with videoconferencing technologies and logistical issues (e.g. work laptops not being equipped with cameras) were barriers to using videoconference. P4 (a community provider) expressed concerns that remote visits would not allow providers to identify essential issues in the way that in-person visits would:

"What is missing now is the in-person visits to client’s homes. There is no replacement to that. To physically see someone how someone moves around, to physically see their environment, you know? Everything. The smell, the feel, the walking up to the building, all those issues. Walking through the door, are they able to get their wheelchair over the door threshold? You know what I mean? There is all these things you wouldn’t notice even in a virtual environment that I think is definitely missing at the moment."

Another concern was that using technology with patients who had cognitive, visual or hearing impairments was challenging. However, providers rarely mentioned privacy concerns as many providers trusted their organization’s security measures. Finally, providers indicated that incorporating technology into their workload added another task.

Subtheme 4c perceived opportunities for technology to support transitions.

Providers believed that some aspects of virtual care (e.g. email and phone communication with patients and caregivers) might continue beyond the pandemic. While face-to-face was generally preferred, providers believed that email and phone could supplement or, in some cases, be an alternative to in-person communication. For instance, P11 (hospital provider) indicated that remote communication was beneficial for caregivers as it minimized travel burden and the amount of time they spent in waiting rooms. P1 (a community provider) indicated that phone calls might be appropriate for following up with patients after hospital discharge who have transportation barriers or other conditions limiting their ability to participate in an in-person encounter. Given the pandemic context, virtual care was considered an adequate substitute for in-person communication but not ideal.