Abstract
Background: The SMILE2 service provides integrated virtual case management of patients with multimorbid chronic disease in the community. It is a joint initiative between Caredoc and HSE Enhanced Community Care (ECC) programme together with Chronic Disease Community Specialist teams. The service increases access to care for patients living with 2 or more chronic diseases and prevents deterioration in patient conditions, thereby reducing unscheduled visits to acute care and subsequent admissions by empowering participants with the knowledge to proactively self-manage their health.
Approach: Suitable patients for inclusion in the service are identified by chronic disease hub-based Clinical Nurse Specialists, GP’s, Practice Nurses, or acute hospital staff. When enrolled, monitoring equipment is deployed to the patient in their own home by a SMILE Field Operator who gives a thorough demonstration of the technology; once the digital devices are operational the SMILE Nursing team engages regularly with the patient and reviews the vital sign readings generated from the patient’s digital support kit. Individualised thresholds set for patients trigger alerts when readings are out of range, prompting a call to the patient from a SMILE nurse to investigate and carry out a remote assessment. If the SMILE nurse cannot resolve the problem they liaise as appropriate with the patient’s clinical nurse specialist and/or GP to share the patient’s current health status and agree the appropriate steps to be taken, ensuring integration of the services around the patient. By providing virtual case management, the SMILE service enables earlier detection of clinical decline as well as earlier intervention, thus preventing patients having to attend GPs, primary care, or acute services.
Results: Preliminary data for patients enrolled over 6 months indicate very positive results.
41.4% had a reduction in ED/Hospital visits.
45.5% had a reduction in the bed nights they stayed in hospital.
72.3% of patients experienced symptom stabilisation, demonstrated by a reduction in the number of alerts generated over a 6-month enrolment period.
Patients reported the following additional benefits:
- Feeling supported and minded and empowered to manage their condition.
- Having access to a digital device provides access to other virtual programmes and training including pulmonary and cardiac rehabilitation.
- Patients can use their watches for counting steps during cardiac rehab.
- Feeling more educated/motivated when attending rehab classes and more able to benefit from the classes.
Implications: The virtual case management of multi-morbid patients is an essential element of the Integrated Care Programme for the Prevention and Management of Chronic Disease (ICPCD) clinical Model of Care, and hence an essential part of the HSE Enhanced Community Care programme. The clinical results achieved by SMILE2 both for the reduction in alerts and subsequent saving in ED/hospital admissions and bed nights demonstrates an effective case management service that produces health service savings and supports patients to make sustainable lifestyle changes that improve their health outcomes.