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Telemonitoring Can Be Embedded Successfully in Nurse-Led Care Model


Smartphone-based systems can be used to monitor patients with complex chronic conditions, especially when case managers or other clinicians follow up with occasional phone calls, investigators found.

  • An algorithm obtains patients’ data and sends them messages. It also alerts clinicians when problems occur.
  • One study revealed the telemonitoring program was feasible and accepted by patients.
  • The goal is to provide patients with holistic care, starting the telemonitoring program at discharge to ensure a seamless transition.

Clinicians can adopt telemonitoring in everyday practice, using smartphone-based systems to monitor patients with complex chronic conditions, researchers found.1

The technology works best when patients are monitored by case managers or other clinicians through occasional phone calls.

“The paper was foundational research,” says Emily Seto, PhD, PEng, an associate professor at the University of Toronto’s Institute of Health Policy, Management, and Evaluation. “What I’ve been working on is looking at how a home monitoring system can be used for complex patients. We started out many years ago, looking at heart failure. We developed a mobile phone-based management system that allows us to take measurements at home.”

Data are sent to an algorithm that sends messages to patients and alerts clinicians when necessary.

Health systems and provider groups that wish to start a home monitoring system could begin with heart failure patients. “Some patients get out of the hospital and then just go back to the hospital — frequent fliers,” Seto says. “We targeted heart failure patients first.”

Patients were asked to measure their weight and take their blood pressure. These data were sent to clinicians. “The clinician was alerted, and we didn’t have to look at all data all the time,” Seto says. “We could call the patient to see what was up.”

If necessary, the provider would change their medication and give them instructions. This approach worked well, so researchers explored expanding it beyond the hospital to other patients with complex chronic conditions.

Trial Challenges, Successes

Many people are diagnosed with chronic conditions hospitals are not set up to handle because of the siloed nature of the healthcare industry. “Even family doctors do not maintain or help patients holistically sometimes,” Seto says. “I was interested in how this telemonitoring program may help with care of people with multiple conditions.”

Investigators conducted a trial with home clinicians and patients with heart failure. There were challenges in finding the right patients and getting patients motivated to using the program. Issues in care coordination and other challenges arose, including how providers communicated with each other.

“I went to a conference and talked about some of my work, and a hospital vice president told me about a nursing model of care they were going to do for complex patients,” Seto recalls. “This was exciting because I knew the technology was working.”

They worked as partners on the project and performed a feasibility study on complex patients with multiple chronic conditions. The patients fared well in the feasibility trial.

“Now, we have a different trial going on, and we hope to launch it to understand this new model of care, combined with technology,” Seto adds. “People are coming out of the hospital and have very complex conditions.”

An earlier study of the care model showed patients with heart failure, hypertension and/or diabetes found the program was feasible, and patients accepted and adopted the technology with a moderate to high level of adherence.2 This suggests patients can be helped with the right model of care that is supported with technology, Seto says.

A hospital team, including a nurse practitioner, a registered nurse, a social worker, a dietitian, a pharmacist, a clinical manager, administrators, and a specialist, should support this model. The key is linking it to community care and connecting the hospital’s specialized services to the community.

“Part of the trial is to understand that,” Seto says. “It’s a complex question.”

A healthcare team may use an infrastructure that is different than that of standalone healthcare providers. The goal is to look at patients holistically, thinking about what would be helpful through remote monitoring.

“Ideally, I think if we can get this nurse practitioner to discharge patients from the hospital, it’d be the best scenario,” Seto explains. “They could meet the patient and provide a seamless transition from the hospital. We’re working hard to find pathways for identifying patients who are transitioned into our smart clinic before the discharge.”

It would work best if complex patients were identified while still on the hospital floor and connected to a nurse. Then, the nurse could ensure a seamless transition.

To achieve equity, the program would provide patients with the necessary technology if they do not own a cellphone with a data plan. The program also could offer Bluetooth-enabled devices, such as a blood pressure monitor and a weight scale. These would automatically transfer data from the devices to the app if patients find it difficult to enter the information manually. The team can ask patients if they are adhering to taking measurements or if they have any questions.

“All of these patients should be monitoring these parameters anyway, but we’re making it as easy as possible,” Seto says. “The system uses both Android and iPhone devices, so [some patients] can use their own devices, which lowers the cost.”

The technology is automated and puts little burden on the care team. They do not need to monitor the daily numbers. If the patient’s results are outside acceptable values, the system alerts clinicians.

Case managers also could call patients to reassure them everything looks good. This is important for patient adherence to the program and to ensure they are not experiencing problems.

“Some patients would appreciate a call to see how things are going and to make sure their measurements are all within the target,” Seto explains. “Part of what we’re trying to do here is get data so patients don’t have to come to the hospital if they don’t want to. Patients who have an alert really see the benefit when someone is contacting them right away.”

Developing useful, patient-friendly technology for care management is time-consuming because it can fail if it is implemented incorrectly. “The stuff we do is not a drug where you take it and it works or not,” Seto explains. “The technology we’re putting in is very complicated, and it impacts the way providers work and patients use the equipment.”

If patients cannot interface easily with the equipment, they will not use it. “You may have a great system, but if patients are putting data into the system and they don’t get a phone call from the providers to make sure someone is watching it, then they may think nothing is happening and stop putting in data,” Seto says. “These factors can make and break these programs.”


  1. Gordon K, Seto E, Dainty KN, et al. Normalizing telemonitoring in nurse-led care models for complex chronic patient populations: Case study. JMIR Nurs 2022;5:e36346.
  2. Gordon K, Dainty KN, Gray CS, et al. Experiences of complex patients with telemonitoring in a nurse-led model of care: Multimethod feasibility study. JMIR Nurs 2020;3:Jan-Dec.