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Home monitoring of patients with chronic diseases

Distance monitoring Sweden
Home monitoring of patients with chronic diseases allows district nurses to take care of their patients with a system that makes it possible for the patients to manage a number of medical tests on their own, in their own homes. Patients are given a fitness tracker, blood pressure monitor and/or a set of scales depending on the needs of the specific patient. All devices communicate with a smartphone app that transfers the readings to the care provider. All readings are monitored by the system and if something appears to be wrong or outside of the set limits, a nurse will contact the patient. Assessment forms in the app can be used to screen for mental illness.
Improved quality of life and sense of freedom for the patient as they no longer need to wait on the phone to get an appointment or take time off work to visit a health centre. Health care comes closer to both the caregiver and the patient. Patients that can and want to manage their own care are able to do so. Nurses can then focus on patients who have greater needs.
Patients with chronic diseases in need of regular medical testing or patients at risk for chronic diseases when it comes to prevention, i.e. weight loss and patients under medication. The application is also used by the district nurses in primary care to communicate with the patients. Doctors are consulted by nurses, when needed.
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Quotes/testimonials

“We check blood pressure around 50 times per day. We wouldn't be able to carry out this number of checks at the clinic. You could say that I meet around 50 people, but this is in the digital world”.

- District nurse

Elaboration

Needs and challenges

The region wants to provide a good level of health care with the available funding and for geographical conditions that involve long distances. The average age in the population is rising, leading to a higher burden on healthcare providers.

Tax revenue is also decreasing as a result of there being less people of working age. The region has a high number of health centres and nursing stations, which are very costly to run. Finding smarter ways of working could solve some of these challenges.

Solution and function

Patients who have a smartphone can install an app that communicates with a health tracker, blood pressure monitor and a scale. Blood glucose can be recorded manually using the app.

All readings are sent to a cloud service and are monitored and assessed using artificial intelligence – AI. If any readings appear wrong or outside the set limits, a nurse will contact the patient. The nurse is given different priorities depending on the seriousness of the reading.

Nurses can communicate directly with patients, using text chat or video communication.

Economy

The cost of the solution can be described as follows:

  • The solution costs SEK 200 per patient, per month – including equipment
  • Reduced healthcare utilization at hospitals, fewer bed days, fewer ambulance journeys
  • Education and training is provided by the service provider. The company hiresan assistant nurse who trains patients in how to use the equipment
  • Great potential for scaling up to the entire region
  • 25 new patients added each week

Process

Procedures have been developed during the project. These routines involve testing everything early and cancelling it if it doesn’t work. Weekly meetings are held with the project manager, IT, service provider and people working with monitoring in order to identify problems at an early stage.

  • Innovation procurement has been used.
  • New workflows have been developed for the districts nurses who monitor the patients. Healthcare staff have been able to participate and influence the work.
  • It is very important to find people who become interested and that interest grows. Eventually, even reluctant staff will follow.

Organisation and politics

The Director of Primary Care fully supports the project.

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Follow-up/monitoring

Statistics are easy to view and everything is followed up on a weekly and monthly basis.

Questionnaires can be sent through the system.

Communication

The health centres have their own Facebook pages that include information about how to participate and how to sign up

Open house days are held to provide information about the service and personal invitations are sent to patients to download the app, which is not openly available.

More about effects

Personal contact is preserved using the system and also leads to a closer relationship. Health care comes closer to both the caregiver and the patient. Patients with chronic diseases have an improved quality of life and sense of freedom as they no longer need to wait for an appointment or wait on the phone to reach their health centre.

Even if a patient hasn’t noticed that something is wrong, the nurses can see early signs in the readings and treatment can commence right away. Patients are empowered and can take greater responsibility for their own health.

District nurses can handle many more patients when tests are carried out by the patients themselves, and follow-up can take place up on a daily basis.

Effects for the patient

  • Patients become more free and they don’t have wait on the phone to get an appointment or take time off work to visit a health centre
  • White coat syndrome (a phenomenon caused by anxiety that can be experienced during a visit to a clinic is no longer a factor when patients perform the monitoring at home, It is also easier to fine tune the medication
  • Prevention of stroke
  • Prevention of cardiovascular disease
  • Screening of mental illness

Effects for the care giver

  • Nurses can handle more patients
  • Patients that can and want to manage their own care are able to do so. Nurses can then focus on patients who have greater needs.
  • Better working environment
  • Lower cost of health care

Learnings

Do you want to know more about the solution?

Download the full description (PDF) »

  • It is important to start by identifying individuals who are enthusiastic about this type of solution. This applies to both patients and staff.
  • Patients must have a tablet or smartphone or a more recent version of an iPod
  • Patients may need help configuring and handling the app and medical equipment

The solution can be used in both rural and more urban areas and can be upscaled to the entire region.

Use of the solution for COPD and exhaustion syndrome has started, as well as prevention activities regarding weight, exercise and anti-smoking measures.

Cooperation has started with specialist care regarding heart failure and there are plans to start cooperating regarding asthma/COPD, as well as diabetes.

Elisabeth Sundequist, e-Hälsoutveckling Primärvården / Områdesansvarig Cosmic Primärvården

Primärvårdsstaben, Region Jämtland Härjedalen, Phone: +46 70-2567033, elisabeth.sundequist@regionjh.sewww.regionjh.se

ImagineCare

LifeCareX, Contact person: Gustav Hjelmgren +46 72-5461539