Beyond forced telehealth adoption: A framework to sustain telehealth among allied health services

Abstract

Introduction

As COVID-19 restrictions reduce globally, services will determine what components of care will continue via telehealth. We aimed to determine the clinician, service, and system level factors that influence sustained use of telehealth and develop a framework to enhance sustained use where appropriate.

Methods

This study was conducted across 16 allied health departments over four health service facilities (Brisbane, Australia). It used a multi-method observational study design, involving telehealth service activity data from hospital administrative databases and qualitative interviews with allied health staff (n  =  80). Data were integrated and analysed using Greenhalgh's Non-adoption, Abandonment, Scale-up, Spread, and Sustainability framework.

Results

Increased telehealth use during the peak COVID period reverted to in-person activity as restrictions eased. Telehealth is unlikely to be sustained without a clear strategy including determination of roles and responsibilities across the organisation. Clinician resistance due to forced adoption remains a key issue. The main motivator for clinicians to use telehealth was improved consumer-centred care. Benefits beyond this are needed to sustain telehealth and improvements are required to make the telehealth experience seamless for providers and recipients. Data were synthesised into a comprehensive framework that can be used as a blueprint for system-wide improvements and service enhancement or redesign.

Discussion

Sustainability of telehealth activity beyond the peak COVID period is unlikely without implementation strategies to address consumer, clinician, service, and system factors. The framework can inform how these strategies can be enacted. Whilst developed for allied health disciplines, it is likely applicable to other disciplines.

Introduction

The COVID-19 pandemic brought with it an urgent need to deliver high quality health care at a distance prompting a dramatic increase in telehealth. ¹ This initial surge of ‘emergency-response’ telehealth activity, while enabling the continuity of care during the peak of the lockdown periods, required a substantial change to practice. Building on this work, the issue facing services now is – how can we capitalise on the COVID-19 response to better integrate telehealth into clinical services to ensure delivery of high quality, sustainable services, that meet the needs of our consumers? ¹

Historically, integrating telehealth services into allied health has been limited. This low uptake has been attributed to barriers such as funding, time, infrastructure, equipment, skills, and preference (by consumers and clinicians) for an in-person approach.^1–4 Recognising that challenges exist when implementing new telehealth services, studies of successful large scale implementations of telehealth ² have shown services are best introduced gradually, offering telehealth in the first instance, as an alternate method of service delivery for a proportion of health care interactions. Hence, the implementation process often starts with small feasibility trials, and incrementally builds to a full-service model. Success is also dependent on having support and guidance from local champions. ⁵ The opposite occurred in response to the COVID-19 pandemic, ¹ where allied health services rapidly transitioned to telehealth. With this rapid adoption came both successes and failures.

The unprecedented changes to the health system since COVID-19 created a unique ‘natural experiment’ in our health services. An opportunity now exists to understand how telehealth has been used to date and to develop a framework to support sustained use. ⁶ Whilst other implementation and explanatory frameworks exist to evaluate and offer strategies for sustainability, they are not always applicable to telehealth use in allied health, ⁷ they have been developed without consumer input, ⁸ and developed outside of the Australian healthcare context. ⁹ We aimed to determine the clinician, service and system level factors that influence sustained use of telehealth, and to inform redesign of services to support ongoing use of telehealth.

Methods

Design

We used a mixed-method observational study design, involving telehealth service activity data and allied health service provider interviews and focus groups. Consumer input was also sought but will be reported separately. Data were integrated and analysed using the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework. ¹⁰ The NASSS framework facilitates the evaluation of implementation processes and factors related to technology innovations. The key domains of the NASSS framework – the technology, consumer, health condition, healthcare professional, healthcare organisation, and external environment – derive from a systematic review and empirical studies of health technology implementation. ¹⁰ Ethics approval was obtained from Metro South Health Human Research Ethics Committee (#2020/QMS/65521), and informed consent was obtained from all participants.

Setting

This study was conducted within a metropolitan health service network consisting of four hospitals in Brisbane (Queensland, Australia). The health service network provides health care to a population of more than one million people. Public health services in Queensland are run by a state health department. Telehealth activity across the health network is supported by a dedicated telehealth centre that provides technical support, advice, training, and direction.

Participant recruitment and setting

Data were derived from a subset of 16 allied health departments across the four hospital sites (four allied health departments per site). The 16 departments were purposively sampled, with criteria including both active and limited use of telehealth and a mix of professional groups. The 16 departments recruited included: nutrition and dietetics (n  =  4), occupational therapy (n  =  3), physiotherapy (n  =  2), psychology (n  =  2), speech pathology (n  =  4), and social work (n  =  1). From November 2020 to April 2021 allied health clinicians and managers from each department were invited to participate in small focus groups or interviews to discuss telehealth use within their department. This was further extended in May 2021 to include administrative staff (n  =  7).

Data collection and analysis

Administrative activity data

Administrative activity data were collected retrospectively from June 2019 to August 2021 to capture pre-COVID (June 2019- February 2020), peak COVID-19 restrictions in Brisbane, Australia (March – May 2020) and the period post peak restrictions which included intermittent lockdowns (June 2020 – August 2021). The dataset included the number of outpatient allied health consultations delivered in-person, via telephone, or by video conference each calendar month, and combined both new and review (i.e. follow-up) consultations. Data were presented graphically to compare service volume and modality.

Interview data

Staff interviews were conducted online using the Zoom™ video conferencing platform (https://zoom.us/). All participants completed a demographic questionnaire ahead of the interviews. Researchers independent of the health service (EET, MLT, LJC) and experienced in qualitative interviewing conducted all interviews. The interviews were guided by the domains of the NASSS framework; the interview questions are provided as Supplementary File A.

All interviews were recorded, automatically transcribed using Zoom™ and OtterAI™ transcription software, checked for accuracy, and de-identified (i.e. names and identifying details removed and replaced with pseudonyms). Framework Analysis was used to analyse the data as it is a qualitative method well-suited to applied research. ¹¹ The Framework Analysis sorts key issues and themes in five steps: familiarisation, identifying a thematic framework, indexing, charting, and mapping and interpretation. ¹¹

Indexing (coding) was done deductively using the seven domains of NASSS in NVivo 12. These data were then summarised and charted into a matrix. Matrices were stratified by study site and allied health profession. Four researchers, including one clinician-researcher (EET, MLT, RH, LJC) discussed and categorised the information in each matrix as per the NASSS Framework. Solutions identified throughout the qualitative interviews by the clinicians were synthesised into practical implementation strategies by the coding team.

Results

Activity data

Between July 2019 and August 2021, a total of 184,572 outpatient occasions of services occurred in the 16 allied health departments across the four hospitals. Of these, 74% (n  =  135,973) were provided in-person, 22% via telephone (40,798), and only 4% (7801) by video conferencing. The highest activity of both telephone and video conferencing occurred during peak Brisbane COVID restrictions (March – May 2020). Since then, services gradually reverted to in-person activity. However, both telephone and video conferencing activities remain higher than pre-COVID times. In the six months prior to the COVID-19 pandemic, an average of 34 video conferencing appointments occurred across the allied health departments per month which increased to 502 in August 2021. Telephone appointments continue to occur at a much higher rate (> 4 times higher) than video conferencing with 2340 telephone appointments occurring in August 2021 (Figure 1). Across the four hospitals, the use of telehealth varied with video conferencing comprising 2.4% of total outpatient appointments at Site D, compared to 6.5% at Site C.

Figure 1.

Monthly allied health activity by modality from June 2019 to August 2021 (Color online).

Staff focus groups and interviews

Staff demographics

Although 83 individuals provided consent, a total of 80 allied health staff participated, including 14 managers (individual interviews), 58 clinicians (across 18 focus groups, median 3 per group) and 7 administrative staff (Table 1). Individual manager interviews generally took 30 min (range 25–39 min), focus groups took 50 min on average (range 37–69 min) and administrator phone interviews took approximately 15 min each.

Table 1.

Participant demographics.

Position	Categories	Count (%)
Gender	Female	76 (92)
Age in years	21–30	20 (24)
	31–50	50 (61)
	>50	12 (15)
	Median: 37 (IQR: 31–43)
Professional role	Manager/director	14 (17)
	Clinician	62 (75)
	Administration officer	7 (8)
Professional group	Speech pathology	21 (25)
	Nutrition and dietetics	19 (23)
	Occupational therapy	17 (21)
	Physiotherapy	11 (13)
	Psychology	6 (7)
	Social work	5 (6)
	Other (e.g. allied health in general)	4 (5)
Years working in allied health	Less than 1 year	0 (0)
	1–5 years	18 (22)
	6–10 years	24 (29)
	11–15 years	15 (18)
	16–20 years	13 (16)
	21  +  years	12 (15)
	Median: 10 (IQR: 6–17)
Location	Site A	17 (20)
	Site B	23 (28)
	Site C	18 (22)
	Site D	25 (30)

Key themes

Analysis of focus group and interview data elicited the following key themes:

Forced telehealth adoption has increased clinician reluctance

During COVID restrictions, clinicians were forced to adopt telehealth for a large proportion of their caseload. Most clinicians perceived that telehealth was not appropriate, unsafe, or substandard for some interactions. These feelings may have been exacerbated by lack of experience and resultant low confidence in telepractice. Subsequently, many clinicians quickly reverted to in-person when the option was allowed:

“I don't think we have any services that we will not reinstate face-to- face when we can. We definitely haven't had that complete change where we would now look to do telehealth.” Allied Health Director 14

Generally, it was felt certain activities (e.g. when the clinician is required to touch the consumer or perform a procedure) are best conducted in-person and most clinicians wanted some in-person interaction:

“My motto is you can’t assess an engine by looking at it. End of the day you've got to get your hands in there to see what's actually happening in person. The camera will only give you so much definition and so much information …you might be missing quite a large portion of the picture. So …I'd want to see [them] in person, so I transitioned back to pretty much no telehealth as a result.” Physiotherapy Group 2

A general preference was expressed to meet a new consumer in-person, build rapport, and complete an initial assessment and then determine an appropriate modality of care. Clinicians felt more comfortable conducting reviews by telehealth as opposed to initial assessments.

Services with prior telehealth experience and those providing tertiary (state-wide) care were better equipped to transition to telehealth modalities. Most services, however, started from a very low baseline of telehealth use and low levels of staff confidence. Staff who participated in formalised training and simulated practice sessions reported greater confidence in conducting a telehealth session and lower levels of resistance. However, training needed to be routinely provided to ensure new and rotational staff were competent.

Consumer safety was also a reported concern, with the perception there is an additional risk if consumers perform activities without a clinician physically present. Clear procedures and safety protocols were recommended. Service areas that had higher levels of research evidence (and were aware of the evidence) appeared more willing to integrate telehealth into the service.

Value proposition for clinicians is lacking

Telehealth (particularly telephone calls) was reported to result in lower consumer engagement. Interestingly, some clinicians also appeared less engaged, reporting a lower sense of job satisfaction when providing care purely via telephone and increased fatigue when providing care via video conferencing.

Limited clinician benefits were reported with a perception that telehealth increased their workload and reduced efficiencies. Many clinicians felt telehealth models were less efficient due to technical issues and could not achieve the same outcomes as in-person care. Greater pre-planning of sessions was required, especially if consumers required resources and equipment mailed out prior to the session. In essence, telehealth required greater effort and clinicians needed to see a clear benefit for the consumer to continue using this model.

“It's not always the most appealing option purely from a financial point of view, because it probably costs more money to achieve less activity.” Allied Health Director 11

The desirability of telehealth from the clinician perspective was primarily due to how it could provide greater consumer-centred care by increasing convenience, alleviating transport costs, and improving access (especially for patients who live geographically far from the health service). If they could see clear benefits for their consumers, clinicians were more willing to use telehealth.

“I do have someone who I continue doing telehealth with…She had a lot of other appointments so having to come into the clinic would have been quite onerous on her. And you know she didn't have much money, so the public transport [and also] driving would have been quite difficult and also, she was engaging really well. I'd give her homework to do, and she’d do it. So, I continued doing phone treatment with her, just because, for her it was working.” Psychology Group 2

Telehealth also enabled the clinician to have greater insight into the consumers’ home environment which could benefit therapy planning. Additionally, some services effectively used phone reviews to triage referrals and pre-plan sessions which was reported to increase efficiency.

Lack of organisational readiness inhibited telehealth use; hybrid care needs to be integrated

Multiple system-wide issues were identified that require attention if telehealth is to be normalised. In general, there was a lack of telehealth policies and protocols and the technological infrastructure to deliver telehealth seamlessly. The rapid transition to telehealth came with considerable technology issues including low availability of peripheral devices (e.g. webcams), low data network capacity and the use of multiple video conferencing platforms which caused confusion.

“We also changed between platforms very quickly. In the first five weeks we changed between four different platforms. So, trying to learn the functionality of each of those, plus then teach other staff and admin, and then explain to patients. And then you see a patient for the next time you go, ‘We're not using that platform anymore, we're now using this one. This is how you use this.’ That was very time consuming and was very draining as well.” Occupational therapy group 1

Over time, services transitioned to a more user-friendly video conferencing platform developed by the state health department. However, clinicians reported this could be further enhanced to better facilitate certain clinical activities. Connectivity issues continue to occur, and many services require updated hardware. Some believed the additional use of technology was out of the scope of their usual practice reporting they were ‘clinicians not technicians’.

“We were dealing with hardware, software, poor Wi-Fi, and infrastructure within the hospital [which] was problematic.” Allied Health Director 12

Lack of adequate space to conduct telehealth consultations was also a common issue across all sites, identifying a need for more dedicated spaces. Clinicians are wanting flexible ways of working and want to be able to shift easily between different modalities of care creating hybrid ways of service delivery.

“I find it sometimes challenging, the work environments space. Just sometimes it's really hard to hear people, trying to focus when we’re in a shared workspace.” Occupational Therapy Group 2

Resources such as telehealth protocols and scripts were developed independently by some departments with limited sharing across hospitals. The main change to staff resources occurred among administrative staff who were required to do additional tasks such as pre-appointment technology checks. Clinicians were also frequently booking appointments and reported a larger administrative load as a result.

Clinicians perceive limited consumer demand for telehealth; greater consumer-end support required

Clinicians perceived that very few consumers wanted telehealth. When asked if they had directly asked their consumers or provided the option very few had. Certain perceptions (e.g. that a consumer is too elderly or would not be appropriate for telehealth) meant that some clinicians did not offer telehealth at all to certain sub-populations based on their assumptions.

“And a lot of our patients are older and they … were just happy to wait.” Physiotherapy Group 3

“We found that there was obviously a trend of patients being older adults who weren't very confident with their technology or might not have technology with them to facilitate tele video conferencing so phone just worked best at the time.” Psychology Group 1

Services that provided additional consumer support reported greater telehealth uptake. These included demonstrating the telehealth process with the consumer during the first in-person session, sending an allied health assistant to the consumer's home for the initial telehealth appointment, providing written information ahead of time, and/or having the administration staff troubleshoot with the consumer prior to their appointment.

Framework development

Findings were synthesised using the NASSS framework and applied to each of the seven NASSS domains (Table 2). Changes are required across every level of the health system including clinical department level, health service level and broader state government level to enable high-value telehealth delivery that is integrated and sustained.

Table 2.

Framework for sustaining telehealth in allied health departments.

Domain	Action	Actor
1. Condition	Appropriateness Develop guidelines and provide advice to clinicians about what consumer/session type are most likely to be amenable to telehealth Provide guidance to services and clinicians to assist them to tailor telehealth services to their own clinical needs Considerations: appointment type, clinical task, consumer preference, access to technology, modality (video versus telephone), consumer access to private space, availability of a support person, consumer condition/comorbidities, consumer travel distance, consumables required, consumer using telehealth as avoidance strategy, consumer coming to hospital for other conditions already, health/tech literacy	Clinical service, health facility
2. Technology	Training Train clinicians, administrators, and consumers Provide regular training and make it mandatory Provide refresher training (e.g. for staff turnover or low usage) Train on technology itself, but also on conducting discipline-specific assessments, rapport building, online communication Link clinicians to available centralised support services and training resources for telehealth	External parties (e.g. Universities), clinical service, health facility, state-wide health department
	Video conference platform Consistently use one video conferencing platform for all staff and consumers for all clinical care Implement automated feedback cycle for video platform (i.e. ‘log your issue’, ‘rate your connection’) so it can be iteratively improved via users’ feedback Integration of clinical functionalities into platform (e.g. a virtual ‘whiteboard’ to share writing/drawing and visualisation in real time)	Health facility, state-wide health department
	Hardware Assess and implement fit-for-purpose, user-friendly and appropriate hardware for clinicians (e.g. dual screen monitors, webcams, headsets)	Clinical service, health facility
	Service as a technology provider Consider implementing the use of a loan library of devices for consumers for those who do not have access technology Consider community hubs or spoke sites for consumers to attend appointments	Clinical service, health facility, state-wide health department
3. Value proposition	Consumer safety Develop discipline-specific guidelines to prevent and manage adverse events	Clinical service, health facility,
	Promote telehealth to staff and patients Promote telehealth as a hybrid service model that enhances consumer-centred care Develop scripts for administrative and clinical staff Ensure standardised ways of offering telehealth to consumers Designate telehealth champions	Clinical service, health facility, state-wide health department
	Telehealth service expansion Develop plans and strategies to increase geographical reach of specialist allied health services using telehealth Increase accessibility of telehealth to harder-to-reach population groups (e.g. culturally and linguistically diverse, people with sensory and communication disabilities, people with low digital health literacy)	Clinical service, health facility, state-wide health department
	Evidence Develop and disseminate evidence of Models of care Clinical effectiveness across disciplines and clinical groups Societal benefits (including reductions in C02 emissions) Determining way to increase geographical reach and activity Consumer reported outcomes and experience Economic benefits to both consumer and health service	Clinical service, health facility, state-wide health department
4. Adopter system	Plan telehealth service Determine workflow of telehealth within each clinic Determine clinic type (e.g. telehealth-only sessions, hybrid in-person or telehealth, or ad hoc appointments) Map the consumer journey when planning multidisciplinary services Investigate how booking systems can be adapted to better support telehealth services	Clinical service, health facility, state-wide health department
	Administrative procedures Recognise that additional administration resources are likely to be required for telehealth (e.g. scheduling, pre-appointment technology check) Recognise the administrative officer may be the ‘first point of contact’ for troubleshooting Develop a telehealth procedures manual (especially for rotating staff)	Health facility, state-wide health department
	Audit Identify the additional requirements and needs of the service to conduct telehealth (e.g. training, additional skills and capacity, technology, space) Determine additional funding required to meet any additional identified needs (as per above)	Clinical service
	Invest in consumer capability and experience Reduce the appointment time window or provide a dedicated appointment time for telehealth appointment Designate support person to be available for when consumers require help connecting to telehealth appointment Pre-appointment check Provide consumers with How-To guides and troubleshooting guides	Clinical service, health facility
	Standardise Develop facility protocols about the delivery of telehealth Standardise template of appointments across departments	Health facility
	Clinician support Develop a checklist for telehealth appointments that includes consent, privacy, consumer deidentification check Have a contingency plan for failed technology (e.g. telephone)	Clinical service, health facility
	Space Establish dedicated, private spaces available for telehealth appointments Consider working from home	Clinical service, health facility
5. Organisation	Use of e-mail Develop and publish policy on the use of e-mail for consumer communication. For example, provide clear instructions on how e-mail can be used for consumer communication and integrate e-mail with electronic medical records, and appointment reminders	Health facility, state-wide health department
	Share telehealth resources Implement a repository/resource library to enable consolidation of resources across services, disciplines, and professional bodies Pool available resources and provide clinicians access to evidence regarding telehealth and its uses Share past telehealth projects and positive experiences – sharing success using inter-site and inter-disciplinary meetings	Clinical service, health facility, state-wide health department
	Vision for telehealth Include telehealth as part of strategic plans and vision at multiple levels (executive, departmental) Include video conference platform reliability and stability as a strategic goal Normalise the use of telehealth for all consumers Communicate the vision for telehealth so clinicians are aware of the goals and targets regarding telehealth use and understand the motivation of the service for sustaining telehealth Develop partnerships with universities to support workforce education and collaborative research initiatives	Clinical service, health facility, state-wide health department
	Consumer awareness Increase telehealth awareness for consumers via marketing campaign (e.g. educational videos)	Clinical service, health facility, state-wide health department
	Pandemic and disaster planning Ensure telehealth is integral in pandemic and disaster planning Mandate a minimum level of telehealth activity to ensure clinicians are telehealth-ready	Health facility, state-wide health department
6. Wider context	Funding modes Reform funding models for activity based funding and weighted activity units and include time limits so short phone calls (e.g. under 10mins) are reduced reimbursement and longer phone calls (e.g. 1hour) are equivalent to in-person or video conferencing Fund remote patient monitoring	Health facility, state-wide health department
7. Embedding & adapting over time	Evaluation Audit and evaluate telehealth services including consumer reported outcome and experience measures Establish ongoing quality improvement Mandate reporting and mitigation of adverse events that occur during telehealth appointments	Clinical service, health facility
	Strategy refinement Identify additional population groups that would benefit from telehealth services (e.g. carers, in-patients) and formats (e.g. group-based, peer-support) Investigate additional modalities of care (e.g. hybrid, remote patient monitoring) Continually review which consumer groups/sessions are amenable for telehealth Identify and plan for how advanced technical developments (e.g. virtual reality and wearables) are likely to be integrated into future clinical care.	Clinical service, health facility

Sustained long-term telehealth use is unlikely without system-wide improvements, implementation support, and promoting how telehealth can benefit consumers. First, clearer communication from management is required regarding the vision for telehealth and the strategic plan to bring the vision into reality. Second, broader awareness raising is required to enhance consumers’ understanding of telehealth options and benefits. This is the largest motivator for clinicians and effort here is paramount to telehealth integration. Third, clinicians want to be able to provide flexible, hybrid models of care that require ongoing infrastructure improvements including the provision of dedicated telehealth spaces and structured staff training. These models also need to be appropriately funded. Current funding models reimburse telephone appointments at a much lower flat rate than video conferencing and there are no mechanisms in place to fund other modalities of care (e.g. remote patient monitoring). Lastly, evaluation of the health service needs to be flexible to capture consumer outcomes across multiple modalities of care.

Framework

Solutions to identified issues from clinicians, managers and administrators were generated and synthesised by NASSS domain (Table 2).

Discussion

Whilst allied health services within this metropolitan setting used telehealth extensively during peak COVID-19 restrictions, many have rapidly transitioned back to in-person care delivery. Video conferencing accounted for less than 10% of appointments across each of the four hospitals in August 2021. Limited ongoing use of video conferencing is largely due to a lack of clear value for clinicians, reduced willingness due to the chaotic and forced use of telehealth during COVID-19 restrictions, and the perceived low telehealth demand from consumers. We provide a comprehensive framework based on interview findings from 80 stakeholders including clinicians, managers, and administrative staff to enable greater integration of telehealth in the long-term.

Our findings contribute to the existing international literature, particularly from the United States,^12–14 that have reported reduced telehealth use as services transition back to in-person care as the pandemic progresses. Our results also align with evidence of decision-making processes within the allied health field previously demonstrating it can be difficult to change how things have ‘historically’ been done and that local evidence is often required to show it can be directly applicable to their setting. ¹⁵ Sustaining telehealth use requires considered reflection and proactive action from all levels of the organisation. ⁶ Prior use of telehealth appears to be a key factor in continued and sustained use. This may be facilitated by infrastructure investment and familiarity with technology, but more importantly also a pre-identified need for different models of care and willingness of staff to engage in telehealth delivery. ¹⁶ Findings from a recent study evaluating sustainability of telehealth in allied health aligns with the framework domains. ¹⁷ Cottrell et al. ¹⁷ determined that consumers and clinicians preferred a hybrid model of care for telehealth and similar factors (improved workflow, staff and consumer training, and technical support) were highlighted as crucial to improving sustainability.

From the hospital and health service provider perspective, telehealth is an important aspect of pandemic preparedness and needs to continue to ensure some base level of experience and confidence. Consumers have also consistently indicated that they want a choice in how their care is delivered and are very accepting of allied health care being provided by telephone and video conferencing. ¹⁸ However, the value proposition for clinicians needs to be promoted beyond purely consumer-centric care. When delivered well, telehealth can enhance the productivity of services and in certain instances reduce costs to the health service ¹⁹ and provide societal cost benefits. ²⁰ These additionally benefits need to be promoted. Further, health services that provide universal health care should support consumers to access health services without suffering financial hardship. ²⁰ Part of the reluctance of clinicians to fully embrace telehealth is the perception that in-person care is ‘gold-standard’ care. In reality, the ability to offer a flexible mix of modalities depending on the consumer choice and clinical requirements is a way of providing high quality consumer-centred care. Rather than suggesting one modality over another, services should shift to promoting ‘hybrid’ or ‘enhanced care’ and creating supportive environments that enable such flexibility.

Whilst other implementation and explanatory frameworks exist to evaluate and offer strategies for sustainability, they are not always applicable to telehealth use in allied health. For example, The Khoja- Durrani- Scott framework ⁸ evaluates eHealth adoption, through general themes across the stages of an eHealth programme ‘lifecycle’. The framework is simplified and more generalisable, thus, not as context specific as the framework presented here. Another recently developed explanatory framework is the Planning and Evaluating Remote Consultation Services framework (PERCS). ⁹ This framework, adapted from NASSS, focuses on the ethical predicaments of clinical relationships rather than technical aspects such as training or promotion. PERCS supports the observation that telehealth is not appropriate for all contexts, where the mode of delivery should depend on consumer-specific circumstance ⁹ and that sustainability is directly related to the digital maturity of an organisation. ²¹ Themes were derived from empirical data of remote service use (phone, video, and e-consultations), namely within primary care, in the UK during the pandemic. As such that framework may be less applicable to other contexts without further adaptation. As with all frameworks, application of the framework proposed here will require careful consideration. No single entity across the organisation has carriage of all identified components and clear roles and responsibilities will need to be delineated to ensure appropriate action takes place. Further work will also be required to determine prioritisation of the different components of the framework. Different clinical areas will have varying priorities and this will need to be understood. Methods such as concept mapping have been successfully used by our team to determine service redesign priorities. ²²

A strength of this study is that it included representation of a broad range of allied health departments, across multiple settings and clinical areas. It also captured the views of clinicians, managers, and administrators of these services with a range of telehealth experience, including prior low or no telehealth use. Additionally, a consumer representative on the project team ensured a consumer-centred approach was built into the study design. Further, these findings were synthesised using a robustly developed framework. However, findings are from one health service district and therefore limited to naturalistic generalisation to other health services. Further, input from consumers (surveys and in-depth interviews) have been collected as part of this project which further strengthens this work and will be presented elsewhere.

Conclusion

Following the lifting of COVID-19 restrictions, the use of telehealth within allied health across a metropolitan health service network has rapidly transitioned back to in-person care. Strategic planning is required to sustain telehealth use and ensure it is delivered in a way that enables high quality care and optimises consumer engagement. Our framework can inform how these strategies can be enacted. Whilst developed for allied health disciplines, our framework is likely applicable to other areas of care.