Participants
A total number of 75 adult participants were recruited from four shelters providing mid- and long-term accommodation (with a limit of usually one year that might be extended for one more year) to people experiencing homelessness in Budapest, Hungary. According to the European Typology of Homelessness and Housing Exclusion (ETHOS) classification [30], all four shelters were categorized as 3.2 (temporary accommodation), however, there is a Hungarian tendency that clients use these kinds of shelters for a longer time. Although general healthcare services were available for shelter residents prior to the pilot, their usage was ineffective or underutilized as reported by social workers.
Participation in the telecare pilot was on a voluntary basis. As our clients had never experienced telemedicine and to have a thorough understanding of the service by all potential participants, on-site telecare assistants of the social institutions alongside a written consent form also gave a detailed oral description of the whole project.
For participating in the pilot, only one inclusion criterion was applied: the client had to have at least one pre-existing chronic condition that required regular medical follow-up. Although we did not exclude any disease groups, recruitment was focused on clients with cardiovascular, pulmonary, and metabolic diseases. As tracking medical parameters related to these disease groups was manageable easier with basic medical devices, we assumed that medical decision-making on the remote site could be supported better. Exclusion criteria were the existence of severe cognitive impairment, severe communication disabilities (such as severe hearing or visual impairment), and persistent immobility. These restrictions were applied either for the reason that we were not able to provide mobile devices to cover bedridden clients (the visits were done in a separate room within the shelter facility), or the assistants and the physicians asked it during the preparatory focus group discussion, and we have respected that. They reported that they were not entirely comfortable with treating patients with severe hearing or visual impairments through telemedicine.
Study design
As the first step, participating shelters were chosen operated either by the Hungarian Charity Service of the Order of Malta or a partner institution. We also recruited on-site assistants from the social teams of these shelters. A previous work experience in the healthcare sector was a requirement for the assistants to have a basic knowledge of care pathways.
The final structure of the study, inclusion and exclusion criteria, documentation and response to possible emergency situations were determined during focus group discussions with the participating physicians (n = 3) and on-site assistants (n = 4) before the patient recruitment phase.
Recruitment went on for four weeks before the telecare visits started (between Feb 8 and March 7, 2021). Prior to the first telecare visit, a short medical folder of patient history was filled in by each participant and was available for the physicians.
Each participant of the pilot was invited to six online telecare visits biweekly (every two weeks) with a focus on medical management of chronic conditions. The visits took place on an appointment basis and keeping appointments were facilitated by the on-site assistants. Anonymized accounts of popular video call services were used by the care teams. Telemedical health care was provided by three physicians of the Health Center of the Hungarian Charity Service of the Order of Malta (Budapest, Hungary) consisting of two internal medicine specialists and a primary care physician. The visits took place between March 10 and July 30, 2021.
After completion of the pilot, closing focus group discussions were organized for both physicians and on-site assistants to summarize their experiences. A follow-up survey among available previous clients in all four shelters was completed after four to six months of pilot closure, between November 9 and December 7, 2021. The full design of the study is shown in Fig. 1.
Questionnaires
Both clients on the originating site and physicians on the remote site were asked to complete specific questionnaires regarding their experiences and satisfaction after every online visit. All questionnaires were developed by the research team and fine-tuned after the initial focus group interviews.
The client questionnaire consisted of 11 items and focused on the overall patient experience regarding the telecare visit (on a 5-point Likert scale), the occurrence of any technical difficulties (written description), and feedback on different user aspects of the pilot (e.g., simplicity, comfortability, accountability, and differences to an in-person appointment), also on a 5-point scale. The follow-up client questionnaire consisted of 2 items and asked about the past experience of the pilot and the openness towards participation in a future regular telecare service (both on a 5-point scale).
The physician questionnaire consisted of 14 items focusing on the overall professional experience, technical aspects of the visit, medical relevance, and user experience as a provider. All questionnaires are available both in Hungarian and English versions as additional file [see Additional file 1].
Ethical considerations and safety
Telemedical healthcare services were provided by the Health Center of the Hungarian Charity Service of the Order of Malta, a provider with legal authorization and extensive experience in the primary care of homeless persons.
Online visits were delivered through anonymized accounts of either Facebook Messenger (Meta Platforms Inc., Menlo Park, CA, USA) or WhatsApp (WhatsApp LLC, Menlo Park, CA, USA) without disclosing personal, medical and any other identifiable data in a written form beyond the video calls. All other documents related to the pilot were handled in a paper and pencil form and were only available to personnel included in the pilot under strict medical secrecy.
Written informed consent was obtained in every case and ethical approval of the pilot study was granted as TUKEB:133/2020 and IV/10,927/2020/EKU by the Scientific Research Ethics Committee of the Medical Research Council of Hungary.
There were no adverse events related to telecare reported during the study.
Statistical analysis
Data from different sources with anonymous IDs of patients, physicians, and visits were compiled into an analytical database. Data were analyzed with IBM Statistics (SPSS) 27.0 software (IBM, Armonk, NY, USA). As part of the quantitative analysis, we descriptively examined frequencies, averages, and percentage distributions. In comparing averages between groups, we used the ANOVA model and F-test with a p < 0.05 significance level, and between variables, we used paired T-test with a p < 0.05 significance level. Beyond the descriptive analysis, two linear regression models were built on explaining the doctors’ and patients’ overall rating of telemedicine visits. In these models, the dependent variables were the overall ratings and the explanatory variables were the level of agreement with other statements of physicians and patients, accordingly. In the physicians’ model, the length of the visit, the occurrence of any technical problems, modification of the therapeutic regime, and the measurement of parameters between visits were also involved. In both cases, the linear regression model was executed with the stepwise variable selection method.