Research

Journal of Telemedicine and Telecare

2021, Vol. 27(10) 625–630
Enhancing a community palliative care © The Author(s) 2021
Article reuse guidelines:
service with telehealth leads to efficiency sagepub.com/journals-permissions
DOI: 10.1177/1357633X211048952
gains and improves job satisfaction journals.sagepub.com/home/jtt

Helen M Haydon1,2 , Centaine L Snoswell1,2 ,

Emma E Thomas1,2 , Andrew Broadbent3 , Liam J Caffery1,2 ,
Julie-Ann Brydon3 and Anthony C Smith1,2,4

Abstract
Telepalliative care services enable clinicians to provide essential palliation services to people with a life-limiting illness in or
closer to home. This study aims to explore the costs, service activity and staff experiences resulting from the introduction
of telehealth in a community palliative care service in Queensland, Australia. Pre- and post-activity and cost data from the
2016–2017 and 2019–2020 financial years were examined and staff members interviewed. Accounting for inflation and
standard wage increases, the labour costs before and after the addition of telehealth were approximately equal. There
were small variations in non-labour costs, but these were not directly attributable to the expansion of the telehealth ser-
vices. Overall, the service activity increased by 189% for standard doctor and nurse consultations, due to the increased
efficiency of telehealth compared to the previous outreach (travel) model. Thematic analysis of the staff interview data
generated an overarching theme of Increased Job Satisfaction which staff attributed to the patient-centred nature of the
telepalliative care service, the increased peer support and increased professional development. Compared with the tradi-
tional in-person service, the new telehealth-supported model resulted in equivalent costs, greater efficiency by allowing
palliative care to reach more patients and improved staff job satisfaction.

Keywords
Telehealth, palliative care, job satisfaction, cost, efficiency, telemedicine
Date received: 18 July 2021; Date accepted: 8 September 2021

Introduction Due to its specialised nature, palliative care delivery is

Palliative care aims to address the physical, psychosocial
and spiritual needs of a person diagnosed with a life-
limiting illness, to increase quality of life for the person
and their family.1 Telehealth in palliative care, or telepallia-
tive care, has the potential to increase access to in-home
professional palliative care.2 For people experiencing
symptoms of advanced disease, telehealth can reduce the
discomfort of travel,3 and reduce exposure to diseases
that are often present in clinical environments.4,5
Palliative care within the home can improve pain and
symptom control, increase quality of life, improve family
bereavement, reduce the need for hospital-based care and
provide cost-savings for governments.6–9 Further, many
palliated individuals wish to die in their own homes as it
can offer a source of physical and psychological comfort,
aligning with the concept of a ‘good death’.10,11
However, such wishes are often not fulfilled.6 For instance,
in Australia, in 2019, over half of deaths still occurred in
hospital.12
centralised in major cities of Australia (85% of palliative
medicine physicians work major cities).13 One recent
study found only one-third of people who died of cancer
and 8% with non-cancer conditions received specialised
palliative care, with those who lived outside a major city
being even less likely.14,15
1
Centre for Online Health, The University of Queensland, Australia
2
Centre for Health Services Research, The University of Queensland,
Australia
3
Gold Coast Specialist and Supportive Palliative Care Service, Gold Coast
Hospital, Australia
4
Centre for Innovative Medical Technology, University of Southern
Denmark, Denmark
Corresponding author:
Helen M Haydon, Centre for Online Health, The University of
Queensland, Ground Floor Building 33, Princess Alexandra Hospital,
Woolloongabba, QLD, 4102, Australia.
Email: h.haydon@uq.edu.au
626
Telepalliative care is characterised by clinicians providing
videoconsultations into the home, often with clinical support
from either a community nurse or a palliative care nurse, or
to the patient in a local medical service. Videoconsultations
can be provided by specialist doctors, allied health and
nursing staff. Compared with in-person consultations, tele-
health consultations can reduce financial and time costs for
patients, especially when considering reductions in travel
time.16 Health services can also see a reduction in cost (e.g.
cost avoidance of travel subsidy payments) and increase in
efficiency if the telehealth is a replacement for in-person con-
sultations.17,18 This study aims to explore the service activity,
associated costs and staff experiences resulting from the intro-
duction of telehealth. Telepalliative care services were estab-
lished by the Gold Coast Hospital and Health Services
(GCHHS) Supportive and Specialist Palliative Care
Community Service in Queensland, Australia for patients
and carers living in the region.
Method
This mixed-methods study combines quantitative data
examining costs and service activity before and after the
addition of telehealth and a thematic analysis of semi-
structured staff interviews. For this evaluation, we have
assumed that the clinical outcomes are the same regardless
of consultation method.
Ethics approval was received from the Gold Coast
Hospital and Health Service and Human Research Ethics
Committee (HREC/2019/QGC/51879).
Service description
The GCHHS Community Palliative Care Service started
using telehealth as part of routine care in February 2016
to improve efficiency, increase responsiveness for new
referrals and to support at home care for patients. The tradi-
tional model of palliative care was inefficient as it involved
either the patient or the palliative care team travelling. Since
inception, the telepalliative care used by the GCHHS has
expanded so that professional community carers (e.g.
from non-government organisations) can use this mode of
delivery to consult with palliative specialists, nurses and
allied health professionals.
Quantitative data collection and analysis
Data included cost and service activity data for two financial
years (2016–2017 and 2019–2020). The comparative finan-
cial years were chosen because they provided sufficient time
before and after the implementation of the telehealth-enhanced
service to allow for comparison without considering the period
of initial service implementation.
Cost data was provided by the palliative care team for
2016–2017 and 2019–2020, and included direct costs
Journal of Telemedicine and Telecare 27(10)
related to labour, which have been expressed here a as
full-time-equivalent (FTE) for each role within the
service. Non-labour costs (e.g. fleet car costs) for the
service were provided by the administration team and
were only reported if they were relevant to the telehealth
service implementation. Direct non-medical implementa-
tion costs related to telehealth equipment and internet con-
nections have not been reported as these were provided
prior to the service commencing as part of a state-wide
health service initiative to ensure telehealth capability. All
costs are reported in 2020 Australian dollars and all conver-
sions were conducted using inflation reported by the
Reserve Bank of Australia.19 Costs for physical resources
such as clinic and office space as well as computers and
printers were excluded as they were part of the existing
GCHHS infrastructure.
Service activity for in-person, home visits, telephone and
telehealth (videoconsultations) were compared between the
two financial years with a focus on consultations by either
nurses or doctors (data extraction information in
Supplemental File S1). It should be noted that the final
quarter of the study period includes the beginning of the
coronavirus pandemic (from March 2020). However, the
need for palliative care services remained constant during
this time. Data were used to compare the volume of each
service provided, delineated by quarter, modality and
whether the appointment was new or review, presented in
a tabular and graphical format.
Qualitative data collection and analysis
Between September and November 2019, staff involved
with the community palliative care service (including
medical, nursing, and administrative personnel) were
invited to take part in semi-structured interviews focusing
on the telehealth implementation. Recruitment occurred
through flyers, meeting announcements and word of
mouth (snowballing). Researchers, independent of the
service, conducted the interviews in person or by phone.
Results
Quantitative findings
Labour and non-labour costs were largely the same between
the two comparative years, with FTE for most roles remain-
ing stable and only small changes to non-labour costs.
Offering a telehealth-enhanced community palliative care
service enabled an increased number of consults to be per-
formed with equivalent resources, demonstrating that
increased efficiency can be achieved through telehealth by
mitigating non-essential staff travel for consults.
Labour costs stayed constant between the two financial
years examined in terms of FTE staff allocated within the
team (Table S1), except for the addition of a nurse position
Haydon et al. 627

which occurred as part of planned service expansion and there-
fore was not directly related to the telehealth implementation.
Telehealth related non-labour service costs include those
related to telecommunication, motor vehicles, clinical supplies
and pharmaceuticals. Telecommunication costs increased
from $34,477 in 2016–2017 to $57,960 in 2019–2020, with
an overall increase of $23,483. This increase is partially attrib-
utable to the cost of running telehealth services, but also
related to other service extension projects and the increase in
telecommunication staff needs during COVID-19.
Telecommunication costs do not include the implementation
costs for telehealth services, as these were borne by the state-
wide hospital service as part of a state-wide telehealth rollout
and as part of the new hospital building. It is not possible to
delineate them from other costs.
There was a reduction in the cost for motor vehicles
(approx. $2240), clinical supplies (approx. $64,800) and phar-
maceuticals (approx. $28,900) from the 2016–2017 financial
year to the 2019–2020. However, there were a number of cost-
reduction policies and care model changes between the two
years which would have attributed to this reduction.
Although some of this reduction may have resulted from
less home visits from telehealth, it is unlikely that telehealth
was primarily responsible for the change.
Contributing to these higher levels of satisfaction, staff dis-
cussed the value of: the patient-centred nature of the telepal-
liative service; increased peer support and; increased
professional development.
Efficient patient-centred service. Rather than being over-
whelmed by increased numbers of consultations, staff
were effusive about the telepalliative care service. They dis-
cussed the patient-centred nature of the service and
expressed satisfaction that they could ‘serve’ more people
in need as a result of improved efficiency. They highlighted
multiple aspects of the service that were patient-centred
including: more patients seen, more responsive (quicker
to be seen), patients not needing to travel, inclusion of
family/carers, culturally appropriate care for Aboriginal
and Torres Strait Islander patients, increased access to mul-
tidisciplinary care and more comfortable care in the home.
I think they’re great because the patients are getting access
to a doctor quicker than waiting on home visits. Because a
consultant can sit here and do three or four telehealth’s in a
morning but there was no way they would do three or four
home visits in the same amount of time. So, for time effi-
ciency in getting a doctor consult or a specialist palliative
care consult is the major benefit. (P11)

Activity data
Overall, the service was nearly twice as productive in the
2019–2020 financial year (see Table 1 and Figure 1),
after the introduction of telehealth. This is likely due to
the increased efficiency of the telehealth modality where
the service conducted more consultations with the same
number of staff. In 2019–2020 there was a reduction in
new home visits conducted, likely due to the coronavirus
pandemic rather than the introduction of telehealth (see
supplemental S3 for total consultations divided by quarter).
Qualitative findings
Demographics of the 15 staff interviewed are presented in
Table 2.
Thematic analysis of the staff interview data generated
an overarching theme of Increased Job Satisfaction.
Everybody. I think it’s better for the clinician as an individual.
Once they understand how to do telehealth their lack of down
time, which for them as doctors was quite frustrating when
you have to drive from Tugun to Yatala Pie Shop area and
you’re spending 30–40 min in a car where you’re driving
and therefore you can’t really do anything useful. (P2)
Increased peer support. Clinical staff and community
nursing staff, particularly, expressed feelings of increased
support as a result of the group consultations. Community
staff described how they felt less isolated when they were
in the community.
Our nursing NGOs, we use Blue Care, Anglicare, Ozcare.
They also do link ins. I think you get more satisfaction all
round. The knowledge is shared, people have the opportu-
nity to ask, to suggest, to offer. (P1)

Table 1. Service activity during the 2016–2017 and 2019–2020 financial years per consult mode.

2016–2017 2019–2020 Difference

Consult type New Review Total New Review Total New Review Total

Home visit 289 429 718 55 1488 1543 −234 1059 825
In-person 161 312 473 199 321 520 38 9 47
Telephone 1 910 911 144 954 1098 143 44 187
Videoconference (provider or recipient) 77 110 187 275 901 1176 198 791 989
Total 528 1761 2289 673 3664 4337 145 1903 2048
628
Figure 1. Total consultations according to modality.
But the main reasons for us doing telehealth is about effective-
ness and efficiency and that the patients usually like it a lot
more and the staff have rapid access to medical input. (P2):
Sometimes, when we all speak the same language, what
happens is that we go out as a nurse, you have that conver-
sation, the doctor comes on, the doctor has, basically, the
same conversation, giving virtually the same information.
It’s actually reinforcing what’s being said, rather
than giving them contradictory information. The nice thing
is that the nurse can actually hear what the doctor’s
saying, and can participate, and can actually correct things
if there’s a misconception somewhere. I think telehealth is
a fantastic tool for what we’re doing with our patients. (P8)
Increased professional development. The telepalliative care
service presented a greater opportunity for group consultations
with more than one clinician. Staff highlighted the profes-
sional development benefits that occurred as a result.
I’ve definitely had a good experience with it with the
doctors. Yeah. It’s been good to watch the doctors, how
they do their thing as well. Even though some of it is
medical jargon, we still need to know some of it. You see
a lot of compassion. Yeah. I think I’ve found it interesting,
and I’ve learnt a lot from it, but it’s also learning from what
the doctors are saying. So, I guess telehealth has been the
thing connecting it…if we weren’t doing telehealth, I prob-
ably wouldn’t have seen all that stuff. (P6)
Discussion
Telehealth allowed for an increase in service efficiency and
improved job satisfaction for staff without increasing the
cost or compromising care within the community palliative
care service. When clinicians can connect with patients and
Journal of Telemedicine and Telecare 27(10)
Table 2. Demographics of interviewed staff involved with
telepalliative care.
Gender 12 females 3 males
Age Range: 30–65 years old (M = 48 years old)
Occupation Nursing (n = 6) allied health (n = 5)
Medical (n = 2) administrative (n = 2)
Fourteen (14) participants reported that they did not officially
identify as an Aboriginal and/or Torres Strait Islander person.
One participant did not answer this question.
caregivers virtually and provide a videoconsultation they are
able to provide more care to more patients than other service
models. This aligns with a 2020 report calling for more
investment into palliative care services and an increase in
the provision of care into the home.8 Without telehealth,
clinicians have to either perform home-visits where a large
time investment is required for travel or telephone calls
which lack valuable visual information. This change in
service efficiency and reduction in travel has been found
in many telehealth service evaluations both in palliative
care and other specialties.20–22 The hope is that telehealth
will enable more people to remain at home while receiving
palliative care, in line with their wishes. While telehealth is
not appropriate for all appointments, it does enable time-
sensitive needs to be met within the population.21
Findings from the staff interviews indicated that the tele-
palliative care service enabled a more patient-centred
approach, increased clinical peer support and subsequently,
professional development as a result of multidisciplinary
consultations. Although more research is needed on job
satisfaction and wellbeing for staff involved with palliative
care services, this current study indicates the importance to
staff of delivering a patient-centred service. Clinicians who
support patients with life-limiting illnesses tend to have
strong expectations of standard care.23 The ability to con-
tribute in a meaningful way to someone with a life-limiting
illness and their family creates meaning for palliative care
staff and has the potential to mitigate staff burnout.24
Conversely, where adequate care cannot be delivered,
staff experience frustration.25 The current findings are con-
sistent with research in other health specialties that show the
positive impact that patient centred care can have on job
satisfaction.26 The telehealth service also provided
increased opportunity for multi-clinician consultations,
which lead to an increase in interdisciplinary learning and
supportive alliances during patient care, which has been
found previously to increasing staff resilience.27,28
Improved job satisfaction has previously been associated
with the provision of appropriate professional development
among health professionals29 and increase workforce reten-
tion.30 The introduction of telehealth, may therefore have
extended effects beyond just the job satisfaction of
Haydon et al.
clinicians. However, findings are mixed in the literature as
the impact of professional development on job satisfaction
may be a function of the type of professional development
offered.31
Limitations
Service activity was only examined for nursing and medical
consultations conducted between the two comparative
financial years, as these represent the bulk of the multi-mode
service activity and provide the clearest picture of the effect
of telehealth on the service. Future research could be broa-
dened to explore the effect of telehealth on all clinician
activity within the service. Implementation and break-even
costs were not considered for this service implementation,
because the state health provider had already invested in tel-
ehealth resources for the state. For this reason, the equivalent
costs and efficiency gains observed by this service may not
be replicable for other services. The final quarter of the
2019–2020 year was the start of the coronavirus pandemic,
and while many health services changed during this time the
demand for community palliative care services remained
constant although some staff did work from home.
Conclusion
Enhancing the existing palliative care service with telehealth
resulted in increased service capacity and improved timeli-
ness of care, without compromising services for this vulner-
able population. Telehealth also contributed to improved job
satisfaction for service clinicians. Future research should
explore the clinical effectiveness of the two models as
well as explore the experiences of patients and staff.
Acknowledgements
We thank Dr Danette Langbecker for introducing the Centre for
Online Health (UQ) team to the GC Supportive and Specialist
Palliative Care Team (GCSSPC). Many thanks to Ms Monica
Taylor (UQ) and Mr Stephen Bode (GCSSPC) for their assistance
with conducting the interviews and providing the cost and activity
data.
Declaration of conflicting interests
The authors declared the following potential conflicts of interest
with respect to the research, authorship and/or publication of
this article: Dr Andrew Broadbent and Ms Julie-Ann Brydon
work at the GCHHS Supportive and Specialist Palliative Care
service and were responsible for conceptualisation of the research,
support with data collection and overall review of the manuscript.
However, the evaluation and reporting of findings were performed
independently by the authors from The University of Queensland.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship and/or publication of this article: This
629
work was supported by the Clinical Excellence Division,
Queensland Health.
ORCID iDs
Helen M Haydon https://orcid.org/0000-0001-9880-9358
Centaine L Snoswell https://orcid.org/0000-0002-4298-9369
Emma E Thomas https://orcid.org/0000-0001-8415-0521
Andrew Broadbent https://orcid.org/0000-0003-3987-4998
Liam J Caffery https://orcid.org/0000-0003-1899-7534
Julie-Ann Brydon https://orcid.org/0000-0002-0401-0973
Anthony C Smith https://orcid.org/0000-0002-7756-5136
Supplemental material
Supplemental material for this article is available online.
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