Normalizing Telemonitoring in Nurse-Led Care Models for Complex Chronic Patient Populations: Case Study

Abstract

Background The implementation of telemonitoring (TM) has been successful in terms of the overall feasibility and adoption in single disease care models. However, a lack of available research focused on nurse-led implementations of TM that targets patients with multiple and complex chronic conditions (CCC) hinders the scale and spread to these patient populations. In particular, little is known about the clinical perspective on the implementation of TM for patients with CCC in outpatient care. Objective This study aims to better understand the perspective of the clinical team (both frontline clinicians and those in administrative positions) on the implementation and normalization of TM for complex patients in a nurse-led clinic model. Methods A pragmatic, 6-month implementation study was conducted to embed multicondition TM, including heart failure, hypertension, and diabetes, into an integrated nurse-led model of care. Throughout the study, clinical team members were observed, and a chart review was conducted of the care provided during this time. At the end of the study, clinical team members participated in qualitative interviews and completed the adapted Normalization Measure Development questionnaires. The Normalization Process Theory guided the deductive data analysis. Results Overall, 9 team members participated in the study as part of a larger feasibility study of the TM program, of which 26 patients were enrolled. Team members had a shared understanding of the purpose and value of TM as an intervention embedded within their practice to meet the diverse needs of their patients with CCC. TM aligned well with existing chronic care practices in several ways, yet it changed the process of care delivery (ie, interactional workability subconstruct). Effective TM normalization in nurse-led care requires rethinking of clinical workflows to incorporate TM, relationship development between the clinicians and their patients, communication with the interdisciplinary team, and frequent clinical care oversight. This was captured well through the subconstructs of skill set workability, relational integration, and contextual integration of the Normalization Process Theory. Conclusions Clinicians successfully adopted TM into their everyday practice such that some providers felt their role would be significantly and negatively affected without TM. This study demonstrated that smartphone-based TM systems complemented the routine and challenging clinical work caring for patients with CCC in an integrated nurse-led care model.

Towards A Framework for Implementing Remote Patient Monitoring From an Integrated Care Perspective: A Scoping Review

“…Ferrua et al 48 outlined an RPM system to improve oral medication cancer therapy. Gordon et al 46 conducted interviews with patients and health professionals to inform the development of TM for multi-morbidity chronic disease management (a follow-up article was published recently, 55 which we consulted for further details). Modre-Osprian et al 50 developed a concept combining closed-loop monitoring with a collaborative network for HF management.…”

“…Assessing patients’ perspectives throughout program design 39 , 46 , 48 , 55 allows providers to adapt the intervention to the end-users’ technological and self-management capabilities, as well as understand possible reasons for dissatisfaction with conventional care.…”

“…30,40 Geography, community context and language are also major determinants of technological acceptance. 39,46,55 Service Delivery Patient education and self-monitoring promotion are transversal themes among studies. During enrolment and throughout intervention phases, individuals (and caregivers) are instructed on correctly using TM equipment, educated about their condition, and presented with selfmanagement opportunities, 50 contributing to increase therapeutic adherence.…”

“…40,49,50 Coordination of micro-level decision-making processes (ie, patient-provider interaction) is usually ensured by a coordination pivot (eg, case managers, nurse navigators). In most studies, this role is performed by nurses, 43,46,48,50,55 who conduct activities from answering patients' proactive contacts 48 to leading the entire care model, undertaking all medical coordination decisions. 50 Higher coordination is achieved through a program coordinator, responsible for orchestrating all stakeholders and partners, so they can efficiently work together.…”

“…Caregivers, nurses (specialists or not) and physicians (specialists or general practitioners) are the main actors responsible for monitoring and acting upon clinical deterioration, constituting the core RPM workforce across studies. Other professionals may also play an important role in the intervention, such as other specialty physicians (eg, in the context of HF, endocrinologists, pulmonologists, or psychologists 50 ), dieticians, social workers 46,55 and pharmacists. 43,49 Financing Modre-Osprian et al 50 suggests that RPM configurations such as collaborative TM and "classical TM" could be covered by public funds, while home-care monitoring and selfmanagement would be delivered by private providers, stating, however, that such public-private arrangements might complicate care continuity.…”