Nurse-led integrated care for patients with multiple chronic conditions using telemonitoring
Nurse-led Integrated Care of Complex Patients Facilitated By Telemonitoring: The Safe, Managed, and Responsive Transitions (SMaRT) Study
This study is testing if a nurse-led care program using a smartphone app can help patients with multiple chronic conditions stay healthier and avoid going back to the hospital after being discharged.
Quick facts
| Phase | Not applicable |
|---|---|
| Study type | Interventional |
| Enrollment | 350 (estimated) |
| Ages | 18 Years and up |
| Sex | All |
| Sponsor | University Health Network, Toronto Academic / other |
| Locations | 4 sites (Brampton, Ontario and 3 other locations) |
| Trial ID | NCT05543720 on ClinicalTrials.gov |
What this trial studies
This study evaluates the effectiveness of nurse-led integrated care for patients with multiple chronic conditions through the use of a telemonitoring system called Medly. The trial will take place at four hospitals in Ontario, where patients recently discharged from the hospital will use a smartphone application to monitor their health metrics and symptoms. The app allows for personalized monitoring and provides self-care messages based on the patient's input. The goal is to improve care coordination and reduce the risk of readmission for these complex patients.
Who should consider this trial
Good fit: Ideal candidates are adults aged 18 and older who have been recently discharged from the hospital and have at least one complex chronic condition.
Not a fit: Patients who are not able to comply with the use of the telemonitoring application or have conditions that do not benefit from remote monitoring may not receive any benefit from this study.
Why it matters
Potential benefit: If successful, this approach could enhance the management of multiple chronic conditions and improve patient outcomes by providing timely interventions.
How similar studies have performed: Previous studies using telemonitoring for chronic conditions have shown promising results, indicating that this approach is supported by existing evidence.
Eligibility criteria
Show full inclusion / exclusion criteria
Inclusion Criteria: 1. 18 years of age or older 2. Discharged from hospital or seen within 48 hours of discharge at Health Sciences North (HSN), William Osler Health Systems (WOHS), Women's College Hospital (WCH), and Markham Stouffville Hospital (MSH). 3. Have at least one complex chronic condition (i.e., heart failure, complex obstructive pulmonary disease (COPD), hypertension, diabetes, and/or depression) that would benefit if monitored through telemonitoring. 4. Able to comply with use of the telemonitoring application and applicable peripheral devices (e.g., able to stand on the weight scale, able to answer symptom questions, etc.) 5. Able to read, write and speak English or have a caregiver who is able to do so on their behalf. 6. Patients must have been discharged from hospital within 2 weeks during their recruitment into the study (or will be recruited prior to their discharge). Exclusion Criteria: 1. Patients who are discharged from hospital with the intent to be admitted to a long-term care facility will be excluded.
Where this trial is running
Brampton, Ontario and 3 other locations
- William Osler Health System — Brampton, Ontario, Canada (Recruiting)
- Oak Valley Health Hospital — Markham, Ontario, Canada (Recruiting)
- Health Sciences North — Sudbury, Ontario, Canada (Recruiting)
- Women's College Hospital — Toronto, Ontario, Canada (Recruiting)
Study contacts
- Principal investigator: Emily Seto, PhD — University of Toronto
- Study coordinator: Emily Seto, PhD
- Email: emily.seto@utoronto.ca
- Phone: 416-669-9295
How to participate
- Review the eligibility criteria above with your treating physician.
- Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
- Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.