The eHealth @ Hospital-2-Home project at the University of Stavanger will develop new knowledge about digital follow-up of patients at home. It will investigate how digital follow-up can affect perceived treatment burden, quality of life and readmissions among patients with heart failure, and patients surgically treated for colorectal cancer, in transition from hospital to home. We will test a digital follow-up service that can strengthen the patient's health-promoting competence and coping ability. The project will also test forms of collaboration where nurses actively use digital aids to make their work easier, treatment better, and above all to avoid unnecessary readmissions. The service will be tested in care pathways where patients can meet the hospital digitally, at home, in the critical phase after hospital discharge. In the project's first work package, we have developed the content and function of the digital follow-up service, in close collaboration with patient representatives, the health service (hospitals, GPs), technical staff, and national and international scientific partners. In addition, the project's doctoral fellow has collected data from 30 participants (GPs, nurses, patients) with the intention of informing the content and function of the service. The content consists of information about heart failure and bowel cancer surgery and checklists for symptom registration. Among the functions are measurement of vital measures, such as blood pressure, weight and temperature. The content and functions will be tested in a feasibility study starting in November 2021, as part of work package 2. Patients can also be followed by a chat and video function. Six Nurse Navigators have been recruited from two participating hospitals. They will receive training and simulation in the use of the digital platform DignioPrevent (nurses user interface). In the feasibility study, 30 patients will be recruited from the two hospitals, receive training in using MyDignio (patient user interface), and be monitored digitally for 30 days after discharge from hospital. Thereafter, patients and Nurses Navigators participate in interviews with a focus on evaluating the feasibility testing. The results will inform a randomized, controlled study that is planned for the autumn of 2022. The project's first publication, a systematic, restricted review on effects of digital home follow-up of the long-term and chronically ill, is being revised after review in Journal of Medical Internet Research. We have produced an animation film for use in recruiting and promoting the project, and will participate with two contributions at the Nordic Nursing Research Conference in Copenhagen in October 2021.The project is based on co-creation design and user representatives (patient organizations, healthcare professionals, technologists) have participated in regular meetings, in applications, and in validation work.
The overall aim is to develop a nurse assisted eHealth Service to reduce BoT and increase HRQoL in HF and CRC patients, post-hospital discharge. We use a modified version of the framework of complex interventions proposed by the UK Medical Research Council. The project includes three phases and corresponding work packages; a) developing a nurse assisted eHealth service, b) assessing its feasibility and piloting the service and c) carrying out a RCT. The eHealth intervention will be tested by three assessment points (baseline, within 30 and 90 days) to evaluate effects of the service. Our nurse assisted eHealth service is personalized and will optimize patient BoT and HRQoL, link to a digitalized BoT-software (My Dignio). It supports self-monitoring by letting the patients register their own health-related data, and allow for electronic communication with Nurse Navigator. Its content will aim to meet BoT challenges (e.g. symptom monitoring, nutrition advice, motivational and emotional support, health literacy needs) identified in two pilot studies, from current BoT literature and input by user advisory board. This e-Health service allows the patient to communicate BoT challenges, conduct measurements, respond to clinical questions, and receive self-management support. The project aligns with the priority list of Norwegian Health Authorities on factors that impede and promote integrated, coherent patient and user pathways between hospital and home for NCD patiens with HF and CRC, eliminate unjustified variation in post-hospital health service and avoid adverse and costly re-hospitalizations, and relates to the Regular General Practitioner Scheme when patients are outside hospital.The proposal builds on the expertise within health promotion and long-term illness at University of Stavanger, Stavanger and St. Olavs University Hospitals, including international researchers from the Netherlands, Sweden, UK and USA. Users will be engaged in all steps of the project.