Facilitators of and Barriers to integrating telemonitoring in ALS care: a nationwide implementation study of ALS Home Monitoring & Coaching

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Introduction
We developed and implemented ALS Home Monitoring & Coaching (ALSH&C) in the expertise centre on ALS in Utrecht and tested the implementation for scale up in The Netherlands. The aim was to identify barriers to and facilitators for nationwide implementation of ALSH&C.
Methods
We used a participatory action research approach founded on implementation and evaluation frameworks. Focus group interviews with stakeholders were held online in 10 centres with an ALS Care team. The Theoretical Domains Framework was used to create the interview guide and analyse the results.
Results
94 stakeholders participated including people with ALS, caregivers and healthcare professionals. 31 barriers and 35 facilitators were identified.
Barriers in the domain: A) Innovation (n=9) included lack of pulmonary function testing,lack of integrated systems; B) domain characteristics individuals (n=15) included unreliable patient-reported data, less motivated to change work processes and impaired cognitive or hand function; C) Social, organisational and environmental (n=6) included staff shortage, COVID-19 pandemic; and D) (n=1) included negative impact on reimbursement.Facilitators related to: A) (n=9) included protocolized care, low threshold communication and better insight in disease progression; B) (n=17) included benefits of ALSH&C, motivation for ehealth, increased work attractiveness; C) (n=8) included support in the implementation and support from patient organisation; D) (n=1): included financial compensation for implementation.
Conclusion
This identification of barriers and facilitators can inform implementation strategies of telemonitoring in ALS Care. Future studies should evaluate multifaceted implementation strategies and strengthen the evidence base for the impact on the quality, safety and efficiency of ALS care.

Authors
A.K. Schmidt (1,2)*, E.T. Kruitwagen-van Reenen (1,2), M.L. Dontje (1,2), E. van Wijk (3), E.C.T. Baars (4), R.P.A. van Eijk, (5, 6), J.M.A. Visser-Meily (1,2), A. Beelen (1,2) on behalf of the Study Group ALS Home monitoring & Coaching

Affiliations
1. Department of Rehabilitation, Physical Therapy Science and Sports, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
2. Centre of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Centre, University Medical Centre Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
3. Department of Rehabilitation, Noord West Ziekenhuisgroep, Alkmaar, The Netherlands
4. De Vogellanden Center for Rehabilitation, Zwolle, The Netherlands
5. Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, The Netherlands.
6. Biostatistics & Research Support, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.