The rapid expansion of virtual care during COVID-19 has accelerated interest in virtual hospital-at-home models that deliver hospital-level care in people’s homes through remote monitoring, virtual communication and in-person support when required. These models offer potential benefits for patient-centred care and health equity, but rapid roll-out risks overlooking groups that already face barriers to access, including culturally diverse communities. Within Fraser Health Authority in British Columbia, South Asian residents experience a high burden of chronic disease and persistent obstacles related to language, cultural relevance and service access. Against this backdrop, a regional initiative used an experience-based co-design approach to involve patients, caregivers, clinicians and community organisations in shaping a future virtual hospital-at-home strategy, with a deliberate focus on inclusion, trust and equity.
Engaging Communities To Shape Virtual Care
The initiative was grounded in experience-based co-design (EBCD), a participatory quality improvement methodology that brings together those receiving and providing care to redesign services. The process was adapted into five stages. It began with the creation of a multidisciplinary steering committee including representatives from community organisations, virtual health, a South Asian health institute, equity, diversity and inclusion teams and academic researchers. Over 12 months, this group met regularly to refine the approach, promote culturally relevant methods and interpret emerging findings in the context of the wider health system.
To situate virtual hospital-at-home planning within existing practice, the project drew on a qualitative study with seven health care providers who had experience with remote patient monitoring. Their interviews highlighted both opportunities, such as extended assessment time and stronger therapeutic relationships, and barriers, including limited involvement in early design stages. These perspectives underlined the need to engage clinicians from the outset so that virtual models support, rather than disrupt, clinical workflows and referral confidence.
Patient and caregiver experiences were captured through 20 one-to-one interviews with South Asian community members, conducted in multiple languages with technical support available. Participants were generally open to the concept of receiving hospital-level care at home but described barriers linked to trust, awareness and access. Some families perceived virtual care as less legitimate than hospital-based services, particularly for serious conditions, and worried that early discharge or remote management might signal that concerns were not being taken seriously. Challenges around language, cultural nuance and navigating digital tools compounded these concerns and shaped attitudes towards virtual care.
From these interviews, a 10-minute touchpoint film was produced using video and audio segments from nine participants who consented to inclusion. The film highlighted central themes such as trust in virtual care, language barriers and equitable access. It became a core EBCD tool used to anchor a subsequent co-design workshop in real patient and caregiver experiences and emotions.
Digital Literacy, Training and Community Outreach
The co-design workshop brought together interview participants, steering committee members, clinicians and health system staff. Individuals with sceptical or divergent views were deliberately included to broaden the discussion and challenge assumptions. Using the touchpoint film as a starting point, participants worked through structured design thinking exercises to address key challenge areas identified in the earlier stages: language barriers, digital literacy, comfort and convenience, suitability, quality of care and awareness of available services.
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Digital literacy emerged as a pivotal factor influencing whether people could meaningfully participate in virtual hospital-at-home models. Participants acknowledged that artificial intelligence and other digital tools could strengthen care, but discomfort with technology remained a significant barrier. Hybrid digital training that combined online and in-person instruction was recommended to build confidence, particularly among those with limited prior exposure to digital health platforms. Suggestions included the use of body mapping tools with multilingual glossaries on tablets or similar devices to support symptom communication when language is a barrier, and a 24/7 support line to troubleshoot technical problems and provide reassurance at home. Transparent information about wait times and escalation routes, including digital equivalents of hospital call bells, was seen as important for building trust in remote care.
Training and education were highlighted as essential for both patients and health care providers. Participants emphasised simulation-based learning and hands-on preparation before discharge so that people understood their care plans and what to expect from virtual monitoring. For clinicians, virtual health competencies were seen as necessary to navigate platforms effectively and deliver safe, confident care at a distance. Cultural competency training was also prioritised so that communication with diverse populations could move beyond basic interpretation and plain language, and instead reflect cultural understandings of illness, family roles and decision-making. Multilingual training materials, visual aids and simplified explanations were recommended to support health literacy, alongside structured education that clarified how and where to enter the health system.
Community engagement strategies formed another core thread of the co-design discussion. Participants stressed the importance of going to where people are, for example through community pop-ups, outreach in long-term care and targeted engagement in hospice settings. Peer learning was viewed as particularly effective for older adults who might feel more at ease learning from others in similar circumstances. Social media, online communities, community champions and patient testimonials, especially within South Asian media networks, were identified as ways to raise awareness, share experiences and build motivation to try virtual hospital-at-home services when clinically appropriate.
From Co-Design Insights To System Change
Alongside proposals for digital literacy, training and outreach, participants focused on how processes and data use could support continuous improvement. They highlighted the value of collecting both qualitative and quantitative data, using patient surveys, reviews and ongoing community consultations to refine care models and ensure they remained aligned with patient needs. Global information sharing was seen as an opportunity to learn from other virtual care systems, while clear criteria for when hospital-based or home-based care was most appropriate were viewed as crucial for safe, efficient resource use.
Caregiver inclusion ran through many of the recommendations. Participants noted that younger family members often play a central role in supporting older relatives, especially in South Asian households. Virtual hospital-at-home models that formally recognise and equip caregivers, for example through dedicated education modules and access to information, were seen as more likely to overcome language and technology barriers and to foster shared understanding of care plans.
The post-workshop phase focused on translating co-design outputs into actionable recommendations. The research team conducted thematic analysis of workshop data and shared the resulting priorities with the virtual hospital-at-home development team, which then considered feasibility and sequencing. Follow-up meetings with the steering committee allowed reflection on the process and dissemination of knowledge products such as the touchpoint film and summaries of insights. Although the project was not embedded within the core design cycle of the virtual hospital-at-home programme and only one virtual psychiatric unit was active at the time, the work created a foundation of patient-centred and equity-focused guidance for future expansion.
Implementing experience-based co-design within a large health system presented challenges. Engaging busy clinicians, particularly physicians, proved difficult, and some workshop suggestions extended beyond the direct remit of the local team, underscoring the need for system-wide support and cross-organisational collaboration. Nevertheless, the process demonstrated how centring patient and caregiver voices, including those who are sceptical about virtual care, can surface assumptions, reveal diverse perspectives and generate grounded, community-driven solutions.
Experience-based co-design showed how virtual hospital-at-home planning can be shaped around patient-centred and equity-focused priorities when patients, caregivers, clinicians and community partners work together. The process illuminated barriers linked to trust, language, culture and digital access and generated concrete proposals around hybrid digital literacy support, culturally competent training, caregiver inclusion, community outreach and continuous feedback. These insights offer practical guidance for aligning innovation with the needs and expectations of underserved communities, ensuring that virtual models are not only efficient but also inclusive, acceptable and responsive.
Source: JMIR Human Factors
Image Credit: iStock
