From hospital to home: modelling and evaluation of the feasibility of a nurse-assisted eHealth service to support self-management in patients with non-communicable diseases

Abstract

Background: Global healthcare systems are facing challenges in managing non-communicable diseases (NCDs). Heart failure (HF) and colorectal cancer (CRC) are two common long-term illnesses and examples of NCDs. Despite differences in their diagnosis, treatment, prognosis, and trajectory, they have similar needs for supportive care and self-management skills. They may therefore serve as proxies for the larger NCD community. Living with a long-term illness, such as HF and CRC necessitates self-management and support from healthcare professional (HCPs). The period following hospital discharge is considered particularly vulnerable for patients because they must transition from safe in-hospital care to self-management at home. Furthermore, patients with HF and CRC have demanding and often difficult illness trajectories as well as long-term and debilitating treatment-related side-effects that last long after hospital discharge. As a result, many patients struggle to maintain or establish appropriate self-management behaviors in their daily lives. eHealth interventions can help improve treatment durability by offering support during the transition from hospital to home. However, the use of eHealth in clinical practice remains limited, and evidence on the best ways to model and inform digital services to meet patients’ complex supportive care needs and enable effective, high-quality remote nursing is unclear. Consequently, research is needed to determine how eHealth services can be best developed and implemented to provide individualized self-management support that considers the diverse needs and preferences of people suffering from long-term illnesses. Objectives: The overall aims of this study were two-folded. Sub-study I aimed to model a nurse-assisted eHealth service for self-management support to patients with HF and CRC in the transition from hospital discharge to home. Sub-study II aimed to test and evaluate the feasibility of the eHealth service. The more specific aims were as follows: ✓ To explore the supportive care needs of patients with HF and CRC in transition from hospital to home, and to identify various stakeholders’ views on important content and functions of a future eHealth service (sub-study I). ✓ To evaluate the acceptability and usability of a nurse-assisted RPM intervention for the posthospital follow-up of patients with long-term illness (i.e. HF and CRC) using the core constructs of normalization process theory (sub-study IIa) ✓ To explore patients and nurses’ experiences of digital selfmanagement support during participation in a nurse-assisted RPM intervention (sub-study IIb). Methods: This study adopted a sequential qualitative multi-method approach. In sub-study I semi-structured interviews were conducted with patients with HF (n=10), patients surgically treated for CRC (n=9), nurses (n=6), and general practitioners (n=13). Sub-study II applied a combination of semi-structured interviews and observations (sub-study IIa) and a combination of semi-structured interviews and documents of message exchanges (sub-study IIb). In sub-study II, participants comprised patients with HF (n=17), patients treated for CRC (n=10), and nurse navigators (n=8). Semi-structured interviews formed the core component in both sub-studies, with observations and message exchange documents serving as supplemental components in sub-studies IIa and IIb, respectively. Results: Patients with HF and CRC had unmet informational and emotional needs after hospital discharge and their capability for self-management differed considerably, both within and between groups. When designing new eHealth services, priority should be on ease of use, such as easy access and intuitive user interface, in addition to reliable disease- and symptom specific information, symptom checklists monitoring devices and methods for communicating with Healthcare professionals (sub-study I). The nurse-assisted RPM intervention relied heavily on the social interaction between patients and nurse navigators, and the feasibility of the intervention was determined by the relationship between the receiver and deliverer. RPM contributed to ensuring that patients received support and guidance beyond hospitalization and into the posthospital phase. In addition, RPM improved nurse navigators’ understanding of living with a long-term illness, which may have improved their ability to prepare patients for life at home after hospital discharge (sub-study IIa). The mutual digital engagement of patients and nurse navigators in the RPM intervention resulted in a better understanding of patient’s symptoms and health behaviour. This enabled nurse navigators to support patients in their self-management and patients to participate more effectively in self-management activities (sub-study IIb). Conclusions: This PhD study demonstrates that digitalization of healthcare creates both opportunities and challenges. RPM interventions may improve patient’s knowledge and understanding of their illness while also facilitating self-management support. However, it is essential that the features and content of the digital self-management intervention is tailored to meet the specific supportive care needs of each patient group at target. Furthermore, RPM interventions may cause mixed emotions for some participants. The ambivalence brought on by the RPM intervention may however be mitigated, if not exceeded, by the social interaction and collaborative relationship between patients and nurse. Thus, the significance of incorporating a human component, such as nurses, into RPM interventions should not be underestimated.