Exploring an Innovative Care Model and Telemonitoring for the Management of Patients With Complex Chronic Needs: Qualitative Description Study

摘要: Background: The growing number of patients with complex chronic conditions presents an urgent challenge across the Canadian health care system. Current delivery models are overburdened, struggling to monitor and stabilize needs this patient population. Objective: This qualitative study aimed explore perspectives members team inform development innovative integrated model telemonitoring (TM) for conditions. Furthermore, we explored how these could be successfully embedded support novel care. Methods: A description design was utilized conduct analyze 29 semistructured interviews (n=16) (CTM) (n=13) involved in developing ambulatory facility Southern Ontario. Participants were identified through purposive sampling. Two researchers performed iterative thematic analysis using NVivo 12 (QSR International; Melbourne, Australia) gain insights from examining multiple different participants on needs. Results: revealed 3 themes 13 subthemes, including following: (1) adequate remains challenging needs, (2) into structure model, (3) opportunities TM care. not only continued challenges accessing navigating a fragmented disconnected system but also need more self-management support. Patients CTM described care, clear referral triage processes composing tight-knit circle collaborating interdisciplinary providers led by nurse practitioner (NP). Finally, identified, increasing access communication, ability specific signs symptoms, building clinical workflow around TM-enabled care. Conclusions: Despite entrenched service models, new is acutely needed (CCN). NPs unique position lead can facilitate frequent necessary monitoring CCN than one condition