Exploring an Innovative Care Model and Telemonitoring for the Management of Patients With Complex Chronic Needs: Qualitative Description Study.
Kayleigh Gordon, Carolyn Steele Gray, Katie N Dainty and 3 others
PMID 34345777WHAT IT FOUND
Patients with multiple chronic conditions and their care teams described fragmented access, poor technology sharing, and unmet self-management needs.
They wanted one-location teams centred on a nurse practitioner and telemonitoring alerts triaged by nurses.
Key findings
01Patients and care team members described fragmented care, poor access to services, and difficulty providing comprehensive care.
02Participants wanted a nurse practitioner as central coordinator, and thought nurses could triage telemonitoring alerts.
03Telemonitoring was seen as useful for monitoring metrics patients already track, such as blood pressure, weight, and blood sugar, but only if alert criteria and triage workflow are defined.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study was done at a single organization within a single health network, so the views may not transfer to other settings. Family members and caregivers were not interviewed, although they were described as important to care. Participants had never used a monitoring technology or system, so their views were about potential use rather than lived experience with telemonitoring. The care model was still being developed, so findings describe needs and ideas for workflow, not tested implementation. Patient interviews were conducted only after the soft launch, and no follow-up interviews were done. The sample was purposive and small, with patients required to communicate in English.
Declared interests
The authors declared no conflicts of interest.
The easy way to misread this
Do not read these themes as evidence that telemonitoring or the proposed integrated model improves patient outcomes. The study interviewed patients and care team members about needs and possible workflow. It did not test the model or measure clinical effects.