Abstract
Introduction: The SMILE (Supporting multi-morbidity self-care through Integration, Learning and eHealth) program has been running for over 18 months in the Carlow/Kilkenny area with a varied cohort of over 150 adults living with a chronic condition. The program, implemented by Caredoc in conjunction with NetwellCasala and Trinity College Dublin, enables remote health monitoring via wearable connected devices, by collating healthcare data generated by participants for ongoing nurse-led triage review.
Aims, Objectives, Theory Or Methods: The care provided by the SMILE team is tailored to each participant and their specific needs. The objective of the program is to prevent deterioration in patient conditions and empower participants with the knowledge for proactive self-management of their health. This is achieved using monitoring equipment that provides real-time information to the patient as well as to nurses overseeing their healthcare data. Thresholds set for patients trigger alerts when a reading is out of range, prompting a call to the patient from a triage nurse to investigate and if necessary, advise immediate follow-up with GP or Emergency Department.
Highlights Or Results Or Key Findings: Due to the increase in awareness and management of their health, coupled with the continuing encouragement and support of the triage team, 74% of participants reported more effective self-management as well as a variety of other benefits such as weight loss, increased activity/mobility, smoking cessation and reversal of Type 2 Diabetes. 46% have reported a reduction in unscheduled care episodes (i.e. GP visits/ED admissions) as a result of these improvements.
Patients are encouraged to bring their digital tools to their medical appointments, which allows for a full and comprehensive overview of any improvements in their health as a result of their engagement in the program since their last visit/consult with their treating clinician. With the continued utilisation of the monitoring devices and the access to and interpretation of their own data, patients’ health and digital literacy are enhanced, thus increasing health outcomes and providing participants with the knowledge to take an active role in their own well-being.
Conclusions: Our project streamlined the remote monitoring of our participants and established methods for doing this in a Covid-safe and efficient way without needing to compromise the level of care or communication with patients. The telephone support provided by our nursing team proved to be an effective and people-centred medium for delivering necessary care to participants, as well as being a vital social support to them during lockdowns.
Implications For Applicability/Transferability, Sustainability And Limitations:
The program is demonstrably scalable in that we have recently enrolled a new cohort of patients for a second phase – this is achievable from the reduction in alerts triggered for existing participants, creating more scope for the triage team to interact with and monitor patients who have recently been recruited. Further research outcomes centring on reduction of unscheduled care from this cohort of patients will also be investigated.