Virtual Team-Based Care Planning for Older Adults with Dementia: Enablers, Barriers, and Lessons from Hospital-to-Long-Term Care Transitions

Background: Transitions from hospital to long-term care (LTC) facilities are critical periods for older adults living with dementia, often involving complex medical, cognitive, and psychosocial needs. Virtual team-based care has emerged as a promising strategy to improve communication, coordination, and continuity of care during these transitions. However, there is limited evidence on how such approaches are implemented in practice, particularly with respect to inclusion, equity, and engagement of older adults and families. Objective: This study aimed to identify the enablers and barriers to delivering virtual team-based care to support older adults with dementia in transitioning from hospital to LTC. Methods: We conducted a qualitative study using semi-structured interviews, focus groups, and a policy review. Data were collected from 60 participants, including healthcare providers, older adults, and family care partners across hospital and LTC settings in British Columbia, Canada. Thematic analysis was conducted using a hybrid inductive and deductive approach. Eighteen institutional policies and guidelines on virtual care and dementia transitions were reviewed to contextualize findings. Results: Four themes were identified: (1) enhancing communication and collaboration, (2) engaging families in care planning, (3) digital access and literacy, and (4) organizational readiness and infrastructure. While virtual huddles and secure messaging platforms supported timely coordination, implementation was inconsistent due to infrastructure limitations, unclear protocols, and staffing pressures. Institutional policies emphasized privacy and security but lacked guidance for inclusive engagement of older adults and families. Many participants described limited access to reliable technology, a lack of training, and the absence of tools tailored for individuals with cognitive impairment. Conclusions: Virtual care has the potential to support more coordinated and inclusive transitions for people with dementia, but its success depends on more than technology. Structured protocols, inclusive policies, and leadership commitment are essential to ensure equitable access and meaningful engagement. The proposed VIRTUAL framework offers practical tips for strengthening virtual team-based care by embedding ethical, relational, and infrastructural readiness across settings.