key: cord-0688311-bsvkgxza
authors: Wittmeier, Kristy D.M.; Protudjer, Jennifer L.P.; Wicklow, Brandy A.
title: Reflections on Virtual Care for Chronic Conditions During the COVID-19 Pandemic
date: 2020-12-03
journal: Can J Diabetes
DOI: 10.1016/j.jcjd.2020.11.013
sha: a4873fc25847f9f1b747a6ececf7d865eec68b35
doc_id: 688311
cord_uid: bsvkgxza

nan

With the onset of the 2019 coronavirus disease (COVID-19), health systems have had to pivot to offer alternative ways to provide necessary health care. The widespread adoption of virtual care platforms is one example of a much-needed system change expedited by the pandemic. Virtual care has the potential to substantially improve the reach of health-care services, particularly to rural, remote, marginalized and disadvantaged populations living with chronic illness. While we move through this second wave of COVID-19 in Canada, it is important to recognize and reflect on progress achieved within a health system under pressure and to plan the best next step forward.

The provision of remote or virtual care has been identified as a global priority in recent years. However, before the pandemic, <0.5% of health-care interactions in North America were conducted using video-based technology (1). The existing provincial telehealth infrastructure has been able to accommodate some of the need for video-based appointments during the pandemic but lacks the flexibility and capacity to meet increasing demands, and still requires patients to attend a telehealth site in person to receive care. The pandemic has reduced the capacity for outpatient visits, as staff are redeployed and in-person services are reduced. Virtual care, using a person's in-home technology, has created an opportunity for people with chronic conditions to maintain access to their health-care team while limiting in-person contacts. Virtual care presents the added benefits of reducing travel time and cost, and time away from school or work.

The rapid implementation of virtual care during the pandemic has been an abrupt and bumpy ride, with challenges and lessons learned. Decisions about appropriate secure virtual care platforms, shortages or delays in accessing hardware and ensuring appropriate training for health-care providers, administrative staff, patients and families have been commonly reported stumbling blocks. Lack of system-level change management has resulted in rapid uptake by some providers or clinics, while others lag. Variable levels of access to technology or connectivity for families, especially in economically disadvantaged homes, further contribute to variability in access to virtual care options. Although there are many benefits of virtual care, a keen eye must remain on closing, rather than widening, the health-care equity gaps.

Chronic illness tends to disproportionately affect marginalized populations who may face additional barriers to ongoing medical management, surveillance for comorbidities and prevention of complications. This is exemplified by the high rates of type 2 diabetes within Indigenous groups, particularly First Nations populations in Canada. In this issue of the Canadian Journal of Diabetes, 2 articles highlight the importance of expanding the reach of care systems to achieve equitable access to chronic disease care and care that acknowledges the historic harms and systemic racism that have impacted the health of Indigenous peoples. Dawson et al report on the health benefits of a multidisciplinary diabetes telemedicine clinic with expanded reach to rural and remote First Nations communities, which has engaged community members through trust, respect and relationship building (2) . With mobile clinics reaching more than 60 communities and engaging approximately 99% of individuals known to have diabetes, programmatic screening, health education and promotion resulted in stabilization of glycated hemoglobin and body weight, and improvements in attaining blood pressure and lipid targets. The authors acknowledge that the time between visits (mean, 1.6 years) was longer than recommended and suggest that a mixed model of collaborative community-based and mobile specialist care may address resource issues.

Locke et al examine community and university-based initiatives to address health service gaps (3) . Through community consultation, the authors identify priority areas for addressing gaps in diabetes services, including the development of a community-based diabetes hub (centralized diabetes care) and the use of a navigator to assist in an individual care plan. Both articles identify the inadequacy of health services provision in rural and remote areas and the need for novel, relevant and community-driven care options for these populations with high rates of chronic disease. Within the current public health precautions, community-based travel and capacity for local health centres to accommodate additional providers and patients for nonacute care have been limited. A novel solution is required, one that supports the local workforce, allows for consistent specialist consultation and assists the individual through collection of clinical and biochemical parameters necessary for diabetes management, surveillance and prevention of complications. Leveraging virtual care options in combination with in-person care may lessen the impact of public health measures required to prevent the spread of COVID-19 on chronic disease outcomes, and close health equity gaps in the long term.

Virtual care in Canada: Discussion paper

Mobile diabetes telemedicine clinIcs for Aboriginal First Nation People with Reported Diabetes in British Columbia

Improving diabetes care in the British Columbia Southern Interior: Developing community-university initiatives to address service gaps

Conflicts of interest: None.