title: A multi-level qualitative analysis of Telehomecare in Ontario: challenges and opportunities.
abstract: BACKGROUND
  Despite research demonstrating the potential effectiveness of Telehomecare for people with Chronic Obstructive Pulmonary Disease and Heart Failure, broad-scale comprehensive evaluations are lacking. This article discusses the qualitative component of a mixed-method program evaluation of Telehomecare in Ontario, Canada. The objective of the qualitative component was to explore the multi-level factors and processes which facilitate or impede the implementation and adoption of the program across three regions where it was first implemented.
  
  
  METHODS
  The study employs a multi-level framework as a conceptual guide to explore the facilitators and barriers to Telehomecare implementation and adoption across five levels: technology, patients, providers, organizations, and structures. In-depth semi-structured interviews and ethnographic observations with program stakeholders, as well as a Telehomecare document review were used to elicit key themes. Study participants (n = 89) included patients and/or informal caregivers (n = 39), health care providers (n = 23), technicians (n = 2), administrators (n = 12), and decision makers (n = 13) across three different Local Health Integration Networks in Ontario.
  
  
  RESULTS
  Key facilitators to Telehomecare implementation and adoption at each level of the multi-level framework included: user-friendliness of Telehomecare technology, patient motivation to participate in the program, support for Telehomecare providers, the integration of Telehomecare into broader health service provision, and comprehensive program evaluation. Key barriers included: access-related issues to using the technology, patient language (if not English or French), Telehomecare provider time limitations, gaps in health care provision for patients, and structural barriers to patient participation related to geography and social location.
  
  
  CONCLUSIONS
  Though Telehomecare has the potential to positively impact patient lives and strengthen models of health care provision, a number of key challenges remain. As such, further implementation and expansion of Telehomecare must involve continuous assessments of what is working and not working with all stakeholders. Increased dialogue, evaluation, and knowledge translation within and across regions to understand the contextual factors influencing Telehomecare implementation and adoption is required. This can inform decision-making that better reflects and addresses the needs of all program stakeholders.
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Leslie Dan Pharmacy Building, 144 College Street, Toronto, M5S 3M2, ON, Canada. gemma.hunting@theta.utoronto.ca.
authors.forename: Gemma
authors.initials: G
authors.lastname: Hunting
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Leslie Dan Pharmacy Building, 144 College Street, Toronto, M5S 3M2, ON, Canada. nida.shahid@theta.utoronto.ca.
authors.forename: Nida
authors.initials: N
authors.lastname: Shahid
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Leslie Dan Pharmacy Building, 144 College Street, Toronto, M5S 3M2, ON, Canada. yeva.sahakyan@theta.utoronto.ca.
authors.forename: Yeva
authors.initials: Y
authors.lastname: Sahakyan
authors.affiliation: University of Toronto, Toronto, ON, Canada. iris.s.w.fan@gmail.com.
authors.forename: Iris
authors.initials: I
authors.lastname: Fan
authors.affiliation: Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, M5S 3M2, ON, Canada. crystal.moneypenny@mail.utoronto.ca.
authors.forename: Crystal R
authors.initials: CR
authors.lastname: Moneypenny
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Leslie Dan Pharmacy Building, 144 College Street, Toronto, M5S 3M2, ON, Canada. aleksandra.stanimirovic@theta.utoronto.ca.
authors.forename: Aleksandra
authors.initials: A
authors.lastname: Stanimirovic
authors.affiliation: Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Toronto, M5T 1P8, ON, Canada. taylor.north@mail.utoronto.ca.
authors.forename: Taylor
authors.initials: T
authors.lastname: North
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Leslie Dan Pharmacy Building, 144 College Street, Toronto, M5S 3M2, ON, Canada. yelena.petrosyan@theta.utoronto.ca.
authors.forename: Yelena
authors.initials: Y
authors.lastname: Petrosyan
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Leslie Dan Pharmacy Building, 144 College Street, Toronto, M5S 3M2, ON, Canada. murray.krahn@theta.utoronto.ca.
authors.forename: Murray D
authors.initials: MD
authors.lastname: Krahn
authors.affiliation: Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Leslie Dan Pharmacy Building, 144 College Street, Toronto, M5S 3M2, ON, Canada. valeria.rac@theta.utoronto.ca.
authors.forename: Valeria E
authors.initials: VE
authors.lastname: Rac
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D017028:Caregivers / Q000523:psychology; D004059:Diffusion of Innovation; D005260:Female; D006270:Health Facility Administrators / Q000523:psychology; D006282:Health Personnel / Q000523:psychology; D006333:Heart Failure; D006699:Home Care Services; D006801:Humans; D007407:Interviews as Topic; D008875:Middle Aged; D009864:Ontario; D015397:Program Evaluation; D029424:Pulmonary Disease, Chronic Obstructive; D036301:Qualitative Research; D017216:Telemedicine / Q000706:statistics & numerical data*; D057170:Translational Research, Biomedical