Telemonitoring for Patients with Complex Chronic Conditions in Nurse-led Integrated Care

Patients with complex chronic conditions (CCC) represent a significant challenge to the Canadian health care system. The heterogeneity of patients with complex and multi-morbid conditions does not align with current models of care delivery. The system of health care delivery in Canada is built on a foundation which continues to be focused on single chronic conditions. These single silos do not effectively bridge sudden, and frequent episodic health encounters to broader care plans impeding the delivery of person-centered care overall. This dissertation explores a nurse-led integrated chronic care delivery model, using telemonitoring (TM) as an intervention to facilitate better information sharing, improved patient self-care and needs-based clinical care practices. A multi-method study was conducted in three phases to determine 1) what are the opportunities of nurse-led models of care in complex chronic disease management, 2) to explore the needs and perspectives of patients and providers to inform the development of an innovative integrated model of care and the needs of TM for patients with CCC, and 3) to determine the feasibility of implementing a smartphone-based TM system into a nurse-led integrated care model. This work details how TM can be introduced and embedded within the processes of everyday clinical work for clinicians caring for this complex chronic patient population. Patients demonstrated high adherence rates and perceived the smartphone-based TM platform for CCC as useful in managing their everyday routines. The nurse-led team successfully embedded the technology into their regular clinical work as TM aligned well existing complex chronic care delivery practices and could facilitate the high-touch care requirements as a co-located interdisciplinary team. TM-enabled nurse led care models were viewed as a ‘wedge' to fill the growing gap between primary and acute care, fulfilling a need care for complex chronic patients. To our knowledge, this is the first study to evaluate feasibility of TM in this novel nurse-led integrated care model for patients with CCC. This thesis lays the foundations for future research to improve implementations of nurse-led integrated care models as well as outline opportunities which evaluate efficacy and health utilization of TM in this high-risk and high-needs population.

Department dc:contributor.department

Health Policy, Management and Evaluation

Year dc:date.issued

2021

Author dc:creator

• Gordon, Kayleigh Helen

Advisor dc:contributor.advisor

• Seto, Emily

• Health informatics
• Health information
• Health services research
• Telemonitoring

Statement dc:rights

• Attribution-NonCommercial 4.0 International

Licence dc:rights.uri

• http://creativecommons.org/licenses/by-nc/4.0/

Handle dc:identifier.uri

http://hdl.handle.net/1807/104869

OAI identifier oai:identifier

oai:utoronto.scholaris.ca:1807/104869