Evaluation of Nurse-led Integrated Care of Complex Patients Facilitated By Telemonitoring: The SMaRT Study

Launched by UNIVERSITY HEALTH NETWORK, TORONTO · Sep 13, 2022

Keywords

ClinConnect Summary

The SMaRT Study is looking at a new way to help patients who have multiple chronic health conditions, such as heart failure, diabetes, and depression. This study aims to create a nurse-led clinic that uses telemonitoring, which means patients will use technology to keep track of their health at home. This approach hopes to improve communication between patients and their healthcare teams, making it easier for everyone to manage their care effectively and prevent health issues from getting worse.

To participate in the study, you need to be 18 years or older and have been recently discharged from a hospital, showing signs of one or more complex chronic conditions that could benefit from being monitored. You should be able to use a telemonitoring application and devices, like a weight scale, and you or a caregiver must be able to speak and understand English. If you join, you can expect to receive support from nurses who will help you manage your health from home, and your progress will be monitored over the course of the study. This trial is currently recruiting participants, and it aims to find better ways to care for people with complex health needs.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • 1. 18 years of age or older
• • 2. Discharged from hospital or seen within 48 hours of discharge at Health Sciences North (HSN), William Osler Health Systems (WOHS), Women's College Hospital (WCH), and Markham Stouffville Hospital (MSH).
• • 3. Have at least one complex chronic condition (i.e., heart failure, complex obstructive pulmonary disease (COPD), hypertension, diabetes, and/or depression) that would benefit if monitored through telemonitoring.
• • 4. Able to comply with use of the telemonitoring application and applicable peripheral devices (e.g., able to stand on the weight scale, able to answer symptom questions, etc.)
• • 5. Able to read, write and speak English or have a caregiver who is able to do so on their behalf.
• • 6. Patients must have been discharged from hospital within 2 weeks during their recruitment into the study (or will be recruited prior to their discharge).
• Exclusion Criteria:
• • 1. Patients who are discharged from hospital with the intent to be admitted to a long-term care facility will be excluded.