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HELSEVEL-H-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.

Norway - with a small population of 5.3 million - has one of the world's highest rates of colorectal cancer, with over 4,000 new cases annually. Similarly, the incidence of heart failure is considerable with 20000 hospitalizations per year. Both diseases are typical of chronic conditions and with significant re-admission rates 30 days after discharge from hospital. Many patients with chronic illnesses may struggle to navigate the health care system and perform recommended self-care. Treatment burden is the extra work that patients with long-term illness do to live well with the disease. This "extra work" consists of monitoring health status, dealing with treatment plans delegated by the health care providers, and administering medical appointments. The dominant consequences of an excessive treatment burden are reduced health and well-being, inadequate follow-up of treatment plans and re-admissions. The eHealth@Hospital-2-Home project will develop new knowledge about treatment burden and its effect on quality of life. The aim is to explore treatment burden in transitional phases and follow-up of illness and treatment. We will test an eHealth solution that can strengthen the health-promoting competence and coping skills of the chronically ill. At the heart of the project are new digital tools and forms of interaction for patients and healthcare professionals. The eHealth solution will be tested in treatment pathways at the critical stage following hospital discharge. Together with the health care service (hospitals, general practitioner), patient representatives will assist in the design of the digital service. The project will also try out forms of collaboration where nurses actively use digital aids to make work easier, treatment better and, above all, avoid unnecessary re-admissions.

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.

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