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

Kayleigh Gordon, Emily Seto, Katie N Dainty, Carolyn Steele Gray, Jane DeLacy, Kayleigh Gordon, Emily Seto, Katie N Dainty, Carolyn Steele Gray, Jane DeLacy

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.

Keywords: CCC; NP-led care; TM; clinical team; complex chronic conditions; disease; disease care model; integrated care; mobile phone; models of care; nurse; nurse practitioner; nurse-led implementation; telemonitoring.

Conflict of interest statement

Conflicts of Interest: ES is considered one of the inventors of the Medly system under the intellectual property policies of the University Health Network (UHN), and may benefit from future commercialization of the technology by the UHN.

©Kayleigh Gordon, Emily Seto, Katie N Dainty, Carolyn Steele Gray, Jane DeLacy. Originally published in JMIR Nursing (https://nursing.jmir.org), 28.04.2022.

References

    1. Sakib MN, Shooshtari S, St John P, Menec V. The prevalence of multimorbidity and associations with lifestyle factors among middle-aged Canadians: an analysis of Canadian longitudinal study on aging data. BMC Public Health. 2019 Feb 28;19(1):243. doi: 10.1186/s12889-019-6567-x. 10.1186/s12889-019-6567-x
    1. Feely A, Lix LM, Reimer K. Estimating multimorbidity prevalence with the Canadian Chronic Disease Surveillance System. Health Promot Chronic Dis Prev Can. 2017 Jul;37(7):215–22. doi: 10.24095/hpcdp.37.7.02. doi: 10.24095/hpcdp.37.7.02.
    1. Roberts KC, Rao DP, Bennett TL, Loukine L, Jayaraman GC. Prevalence and patterns of chronic disease multimorbidity and associated determinants in Canada. Health Promot Chronic Dis Prev Can. 2015 Aug;35(6):87–94. doi: 10.24095/hpcdp.35.6.01. doi: 10.24095/hpcdp.35.6.01.
    1. Pefoyo AJ, Bronskill SE, Gruneir A, Calzavara A, Thavorn K, Petrosyan Y, Maxwell CJ, Bai Y, Wodchis WP. The increasing burden and complexity of multimorbidity. BMC Public Health. 2015 Apr 23;15:415. doi: 10.1186/s12889-015-1733-2. 10.1186/s12889-015-1733-2
    1. Violan C, Foguet-Boreu Q, Flores-Mateo G, Salisbury C, Blom J, Freitag M, Glynn L, Muth C, Valderas JM. Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PLoS One. 2014;9(7):e102149. doi: 10.1371/journal.pone.0102149. PONE-D-14-06227
    1. Moin JS, Moineddin R, Upshur RE. Measuring the association between marginalization and multimorbidity in Ontario, Canada: a cross-sectional study. J Comorb. 2018;8(1):2235042X18814939. doi: 10.1177/2235042X18814939. 10.1177_2235042X18814939
    1. Gallacher K, May CR, Montori VM, Mair FS. Understanding patients' experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med. 2011;9(3):235–43. doi: 10.1370/afm.1249. 9/3/235
    1. Aoki T, Yamamoto Y, Ikenoue T, Onishi Y, Fukuhara S. Multimorbidity patterns in relation to polypharmacy and dosage frequency: a nationwide, cross-sectional study in a Japanese population. Sci Rep. 2018 Feb 28;8(1):3806. doi: 10.1038/s41598-018-21917-6. doi: 10.1038/s41598-018-21917-6.10.1038/s41598-018-21917-6
    1. van Merode T, van de Ven K, van den Akker M. Patients with multimorbidity and their treatment burden in different daily life domains: a qualitative study in primary care in the Netherlands and Belgium. J Comorb. 2018;8(1):9–15. doi: 10.15256/joc.2018.8.119. joc.2018.8.119
    1. Mannucci PM, Nobili A, REPOSI Investigators Multimorbidity and polypharmacy in the elderly: lessons from REPOSI. Intern Emerg Med. 2014 Oct;9(7):723–34. doi: 10.1007/s11739-014-1124-1.
    1. Vetrano DL, Calderón-Larrañaga A, Marengoni A, Onder G, Bauer JM, Cesari M, Ferrucci L, Fratiglioni L. An international perspective on chronic multimorbidity: approaching the elephant in the room. J Gerontol A Biol Sci Med Sci. 2018 Sep 11;73(10):1350–6. doi: 10.1093/gerona/glx178. 4159419
    1. Tortajada S, Giménez-Campos MS, Villar-López J, Faubel-Cava R, Donat-Castelló L, Valdivieso-Martínez B, Soriano-Melchor E, Bahamontes-Mulió A, García-Gómez JM. Case management for patients with complex multimorbidity: development and validation of a coordinated intervention between primary and hospital care. Int J Integr Care. 2017 Jun 20;17(2):4. doi: 10.5334/ijic.2493.
    1. Wozniak L, Soprovich A, Rees S, Al Sayah F, Majumdar SR, Johnson JA. Contextualizing the effectiveness of a collaborative care model for primary care patients with diabetes and depression (Teamcare): a qualitative assessment using RE-AIM. Can J Diabetes. 2015 Oct;39 Suppl 3:S83–91. doi: 10.1016/j.jcjd.2015.05.004.S1499-2671(15)00465-7
    1. Kastner M, Hayden L, Wong G, Lai Y, Makarski J, Treister V, Chan J, Lee JH, Ivers NM, Holroyd-Leduc J, Straus SE. Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review. BMJ Open. 2019 Apr 03;9(4):e025009. doi: 10.1136/bmjopen-2018-025009. bmjopen-2018-025009
    1. Heale R, James S, Garceau ML. A multiple-case study in nurse practitioner-led clinics: an exploration of the quality of care for patients with multimorbidity. Nurs Leadersh (Tor Ont) 2016;29(3):37–45. doi: 10.12927/cjnl.2016.24891.
    1. Li S, Roschkov S, Alkhodair A, O'Neill BJ, Chik CL, Tsuyuki RT, Gyenes GT. The effect of nurse practitioner-led intervention in diabetes care for patients admitted to cardiology services. Can J Diabetes. 2017 Feb;41(1):10–6. doi: 10.1016/j.jcjd.2016.06.008.S1499-2671(15)30027-7
    1. Hansen KT, McDonald C, O'Hara S, Post L, Silcox S, Gutmanis IA. A formative evaluation of a nurse practitioner-led interprofessional geriatric outpatient clinic. J Interprof Care. 2017 Jul;31(4):546–9. doi: 10.1080/13561820.2017.1303463.
    1. Housden L, Browne AJ, Wong ST, Dawes M. Attending to power differentials: how NP-led group medical visits can influence the management of chronic conditions. Health Expect. 2017 Oct;20(5):862–70. doi: 10.1111/hex.12525. doi: 10.1111/hex.12525.
    1. Carryer J, Adams S. Nurse practitioners as a solution to transformative and sustainable health services in primary health care: a qualitative exploratory study. Collegian. 2017;24(6):525–31. doi: 10.1016/j.colegn.2016.12.001. doi: 10.1016/j.colegn.2016.12.001.
    1. Practice standard: nurse practitioner. College of Nurses of Ontario. 2019. [2020-09-01]. .
    1. Heale R, James S, Wenghofer E, Garceau ML. Nurse practitioner's perceptions of the impact of the nurse practitioner-led clinic model on the quality of care of complex patients. Prim Health Care Res Dev. 2018 Nov;19(6):553–60. doi: 10.1017/S1463423617000913. S1463423617000913
    1. Desai AS, Stevenson LW. Connecting the circle from home to heart-failure disease management. N Engl J Med. 2010 Dec 09;363(24):2364–7. doi: 10.1056/NEJMe1011769.
    1. Aminuddin HB, Jiao N, Jiang Y, Hong J, Wang W. Effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life and clinical outcomes in patients with type 2 diabetes: a systematic review and meta-analysis. Int J Nurs Stud. 2021 Apr;116:103286. doi: 10.1016/j.ijnurstu.2019.02.003.S0020-7489(19)30030-6
    1. Yi JY, Kim Y, Cho YM, Kim H. Self-management of chronic conditions using mHealth interventions in Korea: a systematic review. Healthc Inform Res. 2018 Jul;24(3):187–97. doi: 10.4258/hir.2018.24.3.187.
    1. Seto E, Leonard KJ, Cafazzo JA, Barnsley J, Masino C, Ross HJ. Mobile phone-based telemonitoring for heart failure management: a randomized controlled trial. J Med Internet Res. 2012 Feb 16;14(1):e31. doi: 10.2196/jmir.1909. v14i1e31
    1. Seto E, Leonard KJ, Masino C, Cafazzo JA, Barnsley J, Ross HJ. Attitudes of heart failure patients and health care providers towards mobile phone-based remote monitoring. J Med Internet Res. 2010 Nov 29;12(4):e55. doi: 10.2196/jmir.1627. v12i4e55
    1. Seto E, Leonard KJ, Cafazzo JA, Masino C, Barnsley J, Ross HJ. Mobile phone-based remote patient monitoring improves heart failure management and outcomes: a randomized controlled trial. J Am Coll Cardiol. 2011;57(14):E1260. doi: 10.1016/S0735-1097(11)61260-6.
    1. Ware P, Dorai M, Ross HJ, Cafazzo JA, Laporte A, Boodoo C, Seto E. Patient adherence to a mobile phone-based heart failure telemonitoring program: a longitudinal mixed-methods study. JMIR Mhealth Uhealth. 2019 Feb 26;7(2):e13259. doi: 10.2196/13259. v7i2e13259
    1. Yun JE, Park JE, Park HY, Lee HY, Park DA. Comparative effectiveness of telemonitoring versus usual care for heart failure: a systematic review and meta-analysis. J Card Fail. 2018 Jan;24(1):19–28. doi: 10.1016/j.cardfail.2017.09.006.S1071-9164(17)31211-3
    1. Pekmezaris R, Tortez L, Williams M, Patel V, Makaryus A, Zeltser R, Sinvani L, Wolf-Klein G, Lester J, Sison C, Lesser M, Kozikowski A. Home telemonitoring in heart failure: a systematic review and meta-analysis. Health Aff (Millwood) 2018 Dec;37(12):1983–9. doi: 10.1377/hlthaff.2018.05087.
    1. Ong MK, Romano PS, Edgington S, Aronow HU, Auerbach AD, Black JT, De Marco T, Escarce JJ, Evangelista LS, Hanna B, Ganiats TG, Greenberg BH, Greenfield S, Kaplan SH, Kimchi A, Liu H, Lombardo D, Mangione CM, Sadeghi B, Sadeghi B, Sarrafzadeh M, Tong K, Fonarow GC, Better Effectiveness After Transition–Heart Failure (BEAT-HF) Research Group Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the better effectiveness after transition -- heart failure (BEAT-HF) randomized clinical trial. JAMA Intern Med. 2016 Mar;176(3):310–8. doi: 10.1001/jamainternmed.2015.7712. 2488923
    1. Koehler F, Koehler K, Deckwart O, Prescher S, Wegscheider K, Kirwan BA, Winkler S, Vettorazzi E, Bruch L, Oeff M, Zugck C, Doerr G, Naegele H, Störk S, Butter C, Sechtem U, Angermann C, Gola G, Prondzinsky R, Edelmann F, Spethmann S, Schellong SM, Schulze PC, Bauersachs J, Wellge B, Schoebel C, Tajsic M, Dreger H, Anker SD, Stangl K. Efficacy of telemedical interventional management in patients with heart failure (TIM-HF2): a randomised, controlled, parallel-group, unmasked trial. Lancet. 2018 Sep 22;392(10152):1047–57. doi: 10.1016/S0140-6736(18)31880-4.S0140-6736(18)31880-4
    1. Martín-Lesende I, Recalde E, Viviane-Wunderling P, Pinar T, Borghesi F, Aguirre T, Recio M, Martínez ME, Asua J. Mortality in a cohort of complex patients with chronic illnesses and multimorbidity: a descriptive longitudinal study. BMC Palliat Care. 2016 Apr 12;15:42. doi: 10.1186/s12904-016-0111-x. 10.1186/s12904-016-0111-x
    1. Melchiorre MG, Lamura G, Barbabella F, ICARE4EU Consortium eHealth for people with multimorbidity: results from the ICARE4EU project and insights from the "10 e's" by Gunther Eysenbach. PLoS One. 2018;13(11):e0207292. doi: 10.1371/journal.pone.0207292. PONE-D-18-15573
    1. Lessard L, Amyot D, Aswad O, Mouttham A. Expanding the nature and scope of requirements for service systems through service-dominant logic: the case of a telemonitoring service. Requirements Eng. 2020;25(3):273–93. doi: 10.1007/s00766-019-00322-z. doi: 10.1007/s00766-019-00322-z.
    1. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: a systematic review. J Telemed Telecare. 2018 Jan;24(1):4–12. doi: 10.1177/1357633X16674087.
    1. Hammersley V, Parker R, Paterson M, Hanley J, Pinnock H, Padfield P, Stoddart A, Park HG, Sheikh A, McKinstry B. Telemonitoring at scale for hypertension in primary care: an implementation study. PLoS Med. 2020 Jun;17(6):e1003124. doi: 10.1371/journal.pmed.1003124. PMEDICINE-D-19-03237
    1. May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, Rapley T, Ballini L, Ong BN, Rogers A, Murray E, Elwyn G, Légaré F, Gunn J, Montori VM. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci. 2009 May 21;4:29. doi: 10.1186/1748-5908-4-29. 1748-5908-4-29
    1. McEvoy R, Ballini L, Maltoni S, O'Donnell CA, Mair FS, Macfarlane A. A qualitative systematic review of studies using the Normalization Process Theory to research implementation processes. Implement Sci. 2014 Jan 02;9:2. doi: 10.1186/1748-5908-9-2. 1748-5908-9-2
    1. May C, Finch T. Implementing, embedding, and integrating practices: an outline of Normalization Process Theory. Sociology. 2009;43(3):535–54. doi: 10.1177/0038038509103208.
    1. May C. Towards a general theory of implementation. Implement Sci. 2013 Feb 13;8:18. doi: 10.1186/1748-5908-8-18. 1748-5908-8-18
    1. Gordon K, Dainty KN, Steele Gray C, DeLacy J, Shah A, Resnick M, Seto E. Experiences of complex patients with telemonitoring in a nurse-led model of care: multimethod feasibility study. JMIR Nurs. 2020 Sep 29;3(1):e22118. doi: 10.2196/22118. v3i1e22118
    1. May C. Agency and implementation: understanding the embedding of healthcare innovations in practice. Soc Sci Med. 2013 Feb;78:26–33. doi: 10.1016/j.socscimed.2012.11.021. S0277-9536(12)00770-8
    1. Rapley T, Girling M, Mair FS, Murray E, Treweek S, McColl E, Steen IN, May CR, Finch TL. Improving the normalization of complex interventions: part 1 - development of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT) BMC Med Res Methodol. 2018 Nov 15;18(1):133. doi: 10.1186/s12874-018-0590-y. 10.1186/s12874-018-0590-y
    1. Thorne S, Kirkham SR, MacDonald-Emes J. Interpretive description: a noncategorical qualitative alternative for developing nursing knowledge. Res Nurs Health. 1997 Apr;20(2):169–77. doi: 10.1002/(sici)1098-240x(199704)20:2<169::aid-nur9>;2-i.10.1002/(SICI)1098-240X(199704)20:2<169::AID-NUR9>;2-I
    1. Thorne S. Interpretative description: qualitative research for applied practice. 2nd edition. Milton Park, UK: Routledge; 2016. Mar 21,
    1. Thorne S, Kirkham SR, O'Flynn-Magee K. The analytic challenge in interpretive description. Int J Qual Methods. 2004;3(1):1–11. doi: 10.1177/160940690400300101.
    1. Garnett A, Ploeg J, Markle-Reid M, Strachan PH. Self-management of multiple chronic conditions by community-dwelling older adults: a concept analysis. SAGE Open Nurs. 2018;4:2377960817752471. doi: 10.1177/2377960817752471. 10.1177_2377960817752471
    1. Boult C, Wieland GD. Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through". JAMA. 2010 Nov 03;304(17):1936–43. doi: 10.1001/jama.2010.1623.304/17/1936
    1. Gordon K, Steele Gray C, Dainty KN, DeLacy J, Ware P, Seto E. Exploring an innovative care model and telemonitoring for the management of patients with complex chronic needs: qualitative description study. JMIR Nurs. 2020;3(1):e15691. doi: 10.2196/15691. v3i1e15691
    1. Grisot M, Moltubakk Kempton A, Hagen L, Aanestad M. Data-work for personalized care: examining nurses' practices in remote monitoring of chronic patients. Health Informatics J. 2019 Sep;25(3):608–16. doi: 10.1177/1460458219833110.
    1. Bagot K, Moloczij N, Arthurson L, Hair C, Hancock S, Bladin CF, Cadilhac DA. Nurses' role in implementing and sustaining acute telemedicine: a mixed-methods, pre-post design using an extended technology acceptance model. J Nurs Scholarsh. 2020 Jan;52(1):34–46. doi: 10.1111/jnu.12509.
    1. Vest BM, Hall VM, Kahn LS, Heider AR, Maloney N, Singh R. Nurse perspectives on the implementation of routine telemonitoring for high-risk diabetes patients in a primary care setting. Prim Health Care Res Dev. 2017 Jan;18(1):3–13. doi: 10.1017/S1463423616000190.S1463423616000190
    1. Brewster L, Mountain G, Wessels B, Kelly C, Hawley M. Factors affecting front line staff acceptance of telehealth technologies: a mixed-method systematic review. J Adv Nurs. 2014 Jan;70(1):21–33. doi: 10.1111/jan.12196.
    1. Mc Namara KP, Breken BD, Alzubaidi HT, Bell JS, Dunbar JA, Walker C, Hernan A. Health professional perspectives on the management of multimorbidity and polypharmacy for older patients in Australia. Age Ageing. 2017 Mar 01;46(2):291–9. doi: 10.1093/ageing/afw200.afw200
    1. Mansell K, Edmunds K, Guirguis L. Pharmacists' scope of practice: supports for Canadians with diabetes. Can J Diabetes. 2017 Dec;41(6):558–62. doi: 10.1016/j.jcjd.2017.08.243.S1499-2671(17)30326-X
    1. Donald M, King-Shier K, Tsuyuki RT, Al Hamarneh YN, Jones CA, Manns B, Tonelli M, Tink W, Scott-Douglas N, Hemmelgarn BR. Patient, family physician and community pharmacist perspectives on expanded pharmacy scope of practice: a qualitative study. CMAJ Open. 2017;5(1):E205–12. doi: 10.9778/cmajo.20160135. 20160135
    1. Gould C, O'Hara R, Goldstein MK, Beaudreau SA. Multimorbidity is associated with anxiety in older adults in the Health and Retirement Study. Int J Geriatr Psychiatry. 2016 Oct;31(10):1105–15. doi: 10.1002/gps.4532.
    1. Read JR, Sharpe L, Modini M, Dear BF. Multimorbidity and depression: a systematic review and meta-analysis. J Affect Disord. 2017 Oct 15;221:36–46. doi: 10.1016/j.jad.2017.06.009.S0165-0327(17)30346-4

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe