Supporting patients to self-monitor in the community

Case study: Allison Moloney, Community Matron, Torbay and South Devon NHS Foundation Trust.

Background of change and intervention

As the COVID-19 pandemic escalated, this case study reported that local primary care services worked differently to support and protect vulnerable patients with long term conditions many of whom were reluctant to seek for many of their health concerns. Across primary care the use of technology has been accelerated and this has helped to reduce face-to-face contact, where relevant, and support home visits when they were more appropriate for the patient.

Learning and advice to be shared

At the Torbay and South Devon NHS Foundation Trust a pilot study provided internet connected equipment to patients with long-term conditions to support self-monitoring. A range of equipment allowed monitoring of:

  • pulse oximeter
  • blood pressure
  • capillary blood glucose

Equipment could also monitor movement in the patient’s home, such as opening of the fridge or use of the kettle. This enhanced monitoring was particularly useful when nurses had challenges in seeing frail patients or those that had high falls risk.

Information and data were collected from remote monitoring equipment and sent to nursing teams via the smart home assistant device. An application was used to create graphs and display trends and ranges. Nurses supported patients to understand the relevant information and how to respond to concerns or changes in their clinical observations and when to take further action.

Smart devices with a screen were provided allowing nurses and patients to see each other during consultations. This was widely welcomed, and such devices enabled nurses to support and reassure patients, for example by supporting, assessing and observing self-administering of insulin.

Nurses developed criteria to identify patients that could safely benefit from these approaches.

Would it be beneficial to retain these changes?

During the pandemic this approach helped keep many vulnerable patients safe by reducing face-to-face contact and in the identification and stratification of which patients required different levels of assessment by a community nurse.

In the future and beyond COVID-19, this learning highlights the opportunities for nurses to integrate technology in their practice to better support and empower patients with long-term conditions in primary care.

Promoting health by working in partnership with patients about their condition and supporting informed choices about the management of their own health is a core nursing role. These approaches are underpinned by these skills and could further support patient activation and self-management beyond the pandemic. Closer monitoring and discussions with nurses supports patients to safely increase their knowledge and understanding of their health condition – helping them to self-care whilst making them more aware of subtle but relevant changes in their observations which may require further advice, help or support.

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