Acceptability of a Novel Telemedication Review for Older Adults in Nursing Homes in France: A Qualitative Study

Figures & data

Figure 1 TMR acceptability of (pre-intervention) and satisfaction with (post-intervention) mixed-methods study design.

Figure 2 GP Interview Guide*.

Table 1 Presentation of Themes and Sub-Themes and Related Interview Discourse Excerpts According to Professional Category

	GP	Nurse	Coordinating Nurse	Coordinating Doctor
1. Difficulties related to drug management for NH residents
	Impossibility to discuss drug management with the patient because of impaired cognitive function	Patient attachment to medications	Vigilance over side effects	Difficulty changing habits
1.1 Specific profile of older adults as a group	“Most of the time, we have to deal with people who have severe cognitive impairment, and I can’t write out a drug prescription in a shared [ie with the patient] well-reasoned manner.”	“For example, Mrs B takes 10 tablets in the morning, and 10 tablets in the evening: It’s tragic, but we can’t take them from her. She counts them. If there’s one missing, she notices. She has a psychological issue and she’s very attached to her drugs. It’s terrible.”	“You give morphine, so you’re going to have to monitor the side effects of morphine. Constipation becomes a disaster, and you have to do a faecal extraction every day, so you have to try and keep both sides happy.”	“They’ve been taking this medication all their life, so any change upsets them.”
	Communication problems	Choice of administration form	Unavailability of some drugs	Unavailability of some drugs
1.2 Nursing home context	“That’s a little bit more complicated in the nursing home context. Indeed, there’s often a small delay in information transmission. There are regular communication problems, different teams do different shifts and they don’t know each other.”	“She cannot swallow, so I had to give her a suppository. It’s not the best treatment choice.”	“We may also require ‘as needed’ medicines. For example, patients will ask us for pain killers, but we don’t have any in our medicine trolley.”	“We don’t have access (in NH) to the same medications that hospitals have. We don’t have the same forms of administration. for drugs. There are some drugs that cannot be found in the pharmacy. Sometimes we receive prescriptions from the hospital but we get stuck because they prescribe a medicine that isn’t at the pharmacy.”
	Difficulties collaborating with other HP		Disinterest of locum GP	NH residents “family-related” difficulties
1.3 External factors	“In general, neurologists prescribe a lot, and when we take away their medications, we must be careful to do things gradually (...). They’ve been prescribed by other doctors; we’ve got to be careful about their being sensitive. Especially specialists, in particular psychiatrists ...”		“(...) Some of them [ie, locum GP] refuse to consult; the doctor who came yesterday refused to consult a patient who was right in front of him because he had no time and because it was his last day to substitute.”	“(...) families and residents, it’s hard, (...), we must explain, but residents, even though they have their cognitive abilities, there are some who we can talk to; with others, it’s difficult. Sometimes you have to explain it to them. Then, you have to discuss it with their family. Well, there are two or three families - not the majority - but they’re difficult ...”
2. Perceptions of different professional roles
	Importance of being open-minded about adopting TMR team’s proposed changes to prescriptions	Nurses’ role	Nurses’ role	Advisory role of NH coordinating doctors
2.1 HP perceptions of their own role	“Implementing prescription changes is a responsibility. For instance, tomorrow, if I do not apply a new medication set out by the hospital, if something happens, and then if the family says to me: “my mother died three days ago, because she left the hospital and you did not follow the new medication set out by the hospital “. In my opinion, it would be my fault and I could be sued.”	“Well, I take care of the medicine trolleys, receiving medications [ie, from the pharmacy], I check if they’ve given the right medication, I adjust them according to treatment changes. Today for example, there have been a lot of treatment changes.”	“I don’t administer a prescription haphazardly. I think about it, I do as I was taught; I call it ‘the doubt culture’”.	“It is also the role of coordinating doctors to intervene with general practitioners, to help them to choose the most appropriate drugs.”
	Importance of nursing assistants		Need for GP who care about NH residents	GP as decision makers
2.2 HP perceptions of the roles of other HP	“When I ask the nurse about the patient’s [intestinal] transit, he or she asks the nursing assistant. It’s the assistant who’s closest to the patient, and when I’m told that a patient is in pain, it’s the assistant who reported it. Pain assessment, they’re [ie, nursing assistants] the ones that do it.”		“(What do we need?) General practitioners who are available, who come here often to see their patients. It’s true that when they follow few residents, or just one, they don’t even come to renew prescriptions.”	“We [ie, coordinating doctors] can give advice, but there must be someone who decides, the general practitioner is the person who the resident trusts, he’s the one who decides.”
3. Facilitators of good practice
	Collaboration and mutual help between GP in NH	Rolled-up medicine sachet drug distribution system	Availability of GP	Importance of having a small number of GP working in the same NH
	“I follow 10 patients, I come once a week, but there are my colleagues, who are here on other days; when I’m here, I consult their patients as well as mine, and when they are here, and I’m not, they consult mine.”	“Now, we have a ‘snail’ [ie, rolled-up medicine sachet] drug distribution system. Well, I think it works very well. Before that, we spent a lot of time preparing the drugs. Well, now, we just have to be careful and check which drugs we distribute; I think it works well.”	“(...) we have general practitioners who answer the phone when we have a problem; we talk about it, we have the answer, not immediately, but I would say in the next half hour.”	“It’s easy because there was doctor J. who followed all the residents; he ended up sharing patients with another doctor; he went into partnership with him; (...) only one resident kept his own general practitioner, it’s easier to manage 2 general practitioners than 20.”
4. Views about the TMR intervention
	TEM-EHPAD viewed as an opportunity to “take control” of NH residents’ prescriptions	TEM-EHPAD viewed as an opportunity to improve practices	TEM-EHPAD viewed as an opportunity to improve practices	TEM-EHPAD viewed as an opportunity to improve practices
4.1 Expectations and positive views	“In my opinion, I don’t think it’ll bring me much, because I think I have enough experience making the right prescriptions ... But for sure, there’ll definitely be a few small things. I’m not fully in charge of my prescriptions yet [because he was newly arrived in the NH at the time]. There’ll definitely be small changes; It’ll be the chance to get a message across, so why not.”	“I don’t know, we can always evolve, we discussed the project a little bit, but I don’t really know what it’ll bring us.”	“There is always a point to having external advice about treatments.”	“Perhaps a review of prescriptions ... It is true that sometimes, when there’s no issue, we renew but we don’t reassess utility of each treatment. We do that only when a new resident arrives, because they’ve just arrived, we don’t know them, we look at the medical history. After, sometimes, with the routine of it all, we forget. A fresh look could be useful.”
	Reduced freedom		Doubts about the TMR intervention
4.2 Fears and negative views	“Maybe this is the future of medicine - an evaluation committee! Before, we dealt with patients, we could prescribe according to our experience, our know-how, etc. Apparently, that’s all over. We’ll be stuck between patient demands on the one hand, and an evaluation committee on the other.”		“If she has had a treatment for 10 years, and everything is going well, even if she takes 15 tablets ... ? Well, I wouldn’t change the treatment.”

Table 2 Compatibility Between Phase 1 Results and the TMR Intervention

Issue or Concern Raised by Results from Phase 1 of the Mixed-Methods Study		Opportunity Offered by the Intervention	Proposed Prescription Adjustments
Difficulties related to NH residents’ medication management
Profile of older adults	Difficulty speaking with people who have severe cognitive impairment	GP will be provided support when writing prescriptions for NH residents and will not be alone in the decision-making process
	“Attachment” of older adults to their medications	Prescription adjustments proposed by the TMR hospital-based team might convince patients of the need to reduce or change their medications
	Difficulty providing medication to patients with several comorbidities	The TMR team will bring a fresh point of view and will make a comprehensive review of patient’s medical profile, consequently leading to more appropriate prescriptions
Nursing home context	Difficulty related to different work shifts		Informing all NH employees and GP about the control trial and communicating the prescription adjustments proposed by the TMR team
	Lack of different forms of medication administration in NH	It is possible that some GP are not aware of all available forms of administration especially when they are new. The TMR team may have a greater knowledge of these items and perhaps a greater knowledge of the different drugs suitable for older adults
	Restricted drug availability in NH in-situ pharmacies
External factors	Pressure from families	The hospital-based TMR team may be perceived as having more legitimacy to prescribe and modify NH residents’ medications	Informing families about the trial study, its design and purposes
	Intervention of too many GP in the same NH	The same standardized prescription procedure will be applied to all residents in all NH	Informing GP about the project and communicating proposed prescription adjustments
	Prescriptions from different specialists	The same standardized prescription procedure will be applied to all residents in all NH	Informing all HP about the project and communicating the TEM-EHPAD controlled trial recommendations
Views about the TEM-EHPAD controlled trial
Fears and negative views	Fear of being controlled		Organizing a meeting with all GP who might participate in the trial to reassure them about its purpose Contact all GP by telephone to ask them if they have questions or comments about the trial
	Fear of additional workload		Ensuring the TMR team proposes only a small number of adjustments to a prescription Not asking HP for any feedback or for recommendations about possible improvements to the intervention
	Worsening of NH resident’s health status due to the interruption or modification of their medications		Providing all HP who might be impacted by the study with a contact number for the TMR team, so they can promptly discuss any concerns or any potential undesirable effects caused by the intervention
	Patient reluctance to be enrolled in the study		Writing simpler intervention information notices for NH residents and their families, and providing training for the coordinating doctors who enroll participants in the trial such that they present the intervention in a clear and positive manner.