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HELSEVEL-Gode og effektive helse-, omsorgs- og velferdstjenester

Nurse Assisted eHealth Service From Hospital to Home: Ameliorating Burden of Treatment among Patients With Non-Communicable Diseases

Alternative title: Sykepleierassistert e-helsetjeneste fra sykehus til hjemmet: lindring av behandlingsbyrde blant pasienter med kroniske sykdommer

Awarded: NOK 12.0 mill.

The project eHealth@Hospital-2-Home at the University of Stavanger will develop new knowledge on remote, digital follow-up and how it can affect self-efficacy for self-management, treatment burden, quality of life and readmissions among patients with heart failure and patients surgically treated for colorectal cancer, following hospital discharge. We will test a digital follow-up eHealth service that can strengthen the patient's health-promoting competence and coping skills. The project will also test collaborative means where nurses actively use digital aids to make work easier, treatment better and, above all, avoid unnecessary readmissions. The service will be tested in a care pathway where the 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 content and functionality of the digital follow-up service, in close collaboration with patient representatives, the healthcare service (i.e. hospitals, GPs), technical staff, and national and international research partners. In addition, the project's PhD student has collected interview data from 30 participants (i.e. GPs, nurses, patients) with the intention of informing the service's content and function. The content consists of information about heart failure and colorectal cancer surgery, and checklists for recording of symptoms. Among the service’s functions is the monitoring of vital measures such as blood pressure, weight, and temperature. We have published a knowledge summary on digital home follow-up for patients with heart failure ( and an article based on the interview study is about to be published ( During December 2021-November 2022, the service's content and function have been tested in a feasibility study, as part of the project's work package 2. The study included 30 patients and colorectal cancer. Patients were trained to use MyDignio (the patient's interface) and were then provided with an IPad, a scale, and blood pressure device or temp gauge. They performed measurements and answered symptom questions daily for 30 days after hospital discharge. The nurse navigators continuously responded to the patient's measurements via the digital platform DignioPrevent (nurses' interface), and communicated the response either via telephone, online chat or video call. After the trial, patients and follow-up nurses were interviewed about their experiences with the service. The results will inform a randomized, controlled study starting in the first quarter of 2023. The results from the feasibility study have been disseminated at national and international conferences and webinars and will be published as a study protocol (submitted for review) and as two research articles focusing on the participants' evaluations and process data. Access the project website here:

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.

Funding scheme:

HELSEVEL-Gode og effektive helse-, omsorgs- og velferdstjenester