The effectiveness of mI SMART:A nurse practitioner led technology intervention for multiple chronic conditions in primary care

Aims:Used as integrated tools,technology may improve access and outcomes of care.A new intervention that integrates multiple technologies called mI SMART has been developed,implemented,and evaluated by Nurse Practitioners.The aim of this paper is to present the initial effectiveness of a webbased,structure of sensors and mobile devices designed to overcome the known health determinant of access to care for rural,chronically ill patients by using technology.Methods:The study was conducted at a community primary-care clinic that provides free healthcare to impoverished adults.Adults with at least one chronic condition,a minimum of 3rd grade reading level,and without dementia/psychosis were recruited.Participants were given a Nexus7 tablet and Bluetooth self-monitoring devices.The intervention lasted for 12 weeks.Blood glucose,blood pressure,and weight were collected using the provided Bluetooth devices and means were evaluated with paired-samples ttests before and after the intervention.Results:Thirty participants were majority female,white,married,high-school educated or less,earning less than$20,000 per annum,and had multiple chronic conditions.Pre-intervention glucose,systolic blood pressure,diastolic blood pressure,weight and Body Mass Index were all reduced after the 12-week intervention.Conclusions:The mI SMART intervention is efficacious for use in improvised adults living in rural areas with multiple chronic conditions.As previously reported,the intervention was also shown to be feasible and acceptable to patients.The next step is a larger randomized controlled trial.

Dose of Telehealth to Improve Community-Based Care for Adults Living with Multiple Chronic Conditions: A Systematic Review

The purpose of this systematic review is to identify evidence of the appropriate dose of telehealth intervention services provided to community dwelling adults experiencing chronic illness or disability related to effectiveness, quality, safety, and cost. Academic Search Complete, CINAHL, MEDLINE, Cochrane, and JBI were searched using combinations of “telehealth or telemedicine or telemonitoring or telepractice or telenursing or telecare AND chronic illness or chronic disease”. Of the identified 449 articles, 47 articles met the inclusion criteria. Most study designs were quasi-experimental one group pre-test post-test (N = 16) with few Randomized Controlled Trials (N = 12). Twenty-three published articles studied the effect of telehealth for one chronic condition (49.9%) while 24 (51.1%) examined the effectiveness of telehealth for multiple chronic conditions. Measurement of telehealth outcomes varied and included efficacy, healthcare utilization, quality, adherence, cost, and safety. No standard measure of dose could be extrapolated. Length of intervention was measured and reported differently in each study. The dose of telehealth services that improve care effectiveness, quality, safety, and cost is still unknown for community dwelling adults experiencing chronic illness. The findings from this systematic review do indicate that longer duration of telehealth services (51 weeks), regardless of modality, produced positive outcomes as opposed to those with shorter durations (37 - 38 weeks) that produced neutral or mixed results. Collecting and reporting data related to clinical workflow such as dose of intervention specific to disease and type of modality is recommended. Rigorous study design including standard measurement at the RCT and Comparative Effectiveness level is still needed.

Part B: The Feasibility and Acceptability of mI SMART, a Nurse-Led Technology Intervention for Multiple Chronic Conditions

Background: An opportunity to improve care of multiple chronic conditions for those living in rural areas of the country may exist through the use of technology. Integrating technology interventions into existing rural health systems allows for increased access to healthcare services and augments self-management ability for patients. However, questions remain about acceptability and feasibility of technology use in rural populations. The purpose of this paper is to present the feasibility of mI-SMART, a HIPAA compliant, web-based, structure of mHealth sensors and mobile devices designed to overcome the known health determinant of access to care for rural, chronically ill patients by using technology. Methods: The study was conducted at a primary-care clinic that provided healthcare at no or low cost to low income adults. Inclusion criteria encompassed adults, with at least one chronic condition, having at least 3rd grade reading level, without having dementia/psychosis. Each participant was given a Nexus7 tablet and Bluetooth self-monitoring devices. Feasibility was evaluated in four ways and acceptability was evaluated with post-intervention questionnaires. Results: Thirty participants [mean age: 52 years (SD: 10.0, range: 29 - 74)] were majority female (70%), white (70%), married (60%), high-school educated or less (56.7%), impoverished (less than $20,000 per annum (56.7%), with multiple chronic conditions (96.7%)). During the trial, all participants were able to transmit data. No error messages were due to the mI-SMART system. Errors were user related and solved with technical support. Mean number of self-monitor transmissions was 219.7 [(SD: 197.4), range: 1 - 733]. Participants logged into the system an average of 163. 1 [(SD: 169.7), range: 2 - 568] times and viewed an average of 1092.1 [(SD: 1205.6), range: 8 - 3851] intervention components. Over eighty-six percent of participants sent data for 12 weeks and 43.1% used the intervention for longer. Conclusions: The mI-SMART system is a feasible option for impoverished persons living in rural areas.

Part A: The Development of mI SMART, a Nurse-Led Technology Intervention for Multiple Chronic Conditions

Background: The treatment of Multiple Chronic Conditions (MCC) is complex for both patients and providers. Used as integrated tools, technology may decrease complexity, remove the barrier of distance to obtain care, and improve outcomes of care. A new platform that integrates multiple technologies for primary health care called mI SMART (Mobile Improvement of Self-Management Ability through Rural Technology) has been developed. The purpose of this paper is to present to development of mI SMART, a nurse-led technology intervention for treating for MCC in primary care. Methods: The creation of mI SMART was guided by the model for developing complex nursing interventions. The model suggests a process for building and informing interventions with the intention of effectiveness, sustainability, and scalability. Each step in the model builds from and informs the previous step. Results: The process resulted in the integrated technologies of mI SMART. The system combines a HIPAA compliant, web-based, structure of mHealth sensors and mobile devices to treat and monitor multiple chronic conditions within an existing free primary care clinic. The mI SMART system allows patients to track diagnoses, medications, lab results, receive reminders for self-management, perform self-monitoring, obtain feedback in real time, engage in education, and attend visits through video conferencing. The system displays a record database to patients and providers that will be integrated into existing Electronic Health Records. Conclusion: By using the model for developing complex nursing interventions, a multifaceted solution to clinical problems was identified. Through modeling and seeking expert review, we have established a sustainable and scalable integrated nurse-led intervention that may increase access and improve outcomes for patients living in rural and underserved areas. The first trial of mI SMART has been completed and evaluated for feasibility, acceptability, and effectiveness in persons in rural areas living with multiple chronic conditions.

Implementation of a Return to Work Strategy in Germany—Are There Changes in Work-Related Rehabilitation Measures and Employment Status in Chronic Conditions?

Objectives: Aging workforces with increasing numbers of chronic conditions require health initiatives with greater workplace focus. A regional pension insurance introduced a Return To Work (RTW) strategy for insurants with chronic conditions. The objective was to identify the degree of implementation of work related measures in medical rehabilitation and the extent of RTW outcomes. Methods: 5883 insurants were considered. Severe Restriction of Work Ability (SRWA), Work-related Medical Rehabilitation (WMR), and Case Management (CM) were examined for 2008 and 2012. An Index of Employment status (IoE) was used in a logistic regression. Results: Utilization of WMR raised from 12.3% in 2008 to 66.1% in 2012. The proportion of insurants with SRWA and WMR grew from 8% up to 40.1%. In 2008, 14.7% of insurants with SRWA received WMR;in 2012, it grew to 76.6%. On the other hand, in 2012 26% got WMR without SRWA and 12.2% had SRWA and got no WMR. CM was not conducted in 2008 but reached 20.2% in 2012. Across all indications, WMR resulted in positive RTW as measured by IoE: OR = 0.75 (KI-95%: 0.67 - 0.86). Conclusion: WMR was successfully implemented according to the German guideline. There is a need to optimize the linkage between SRWA and WMR and CM to provide need-based care.

The Use of Video Conferencing for Persons with Chronic Conditions: A Systematic Review

The purpose of this paper is to present a systematic review of studies that used Video Conferencing (VC) intervention for common chronic conditions. Chronic conditions account for the majority of poor health, disability, and death, and for a major portion of health-care expenditures in the United States. Innovative methods and interventions are needed to enhance care and management, improve access to care, improve patient outcomes, narrow health disparities and reduce healthcare costs. Video Conferencing could be particularly relevant in improving health, care management, access and cost in the care of chronic illnesses. A comprehensive literature search process guided by the PRISMA statement led to the inclusion of 27 articles measuring video conferencing, at least one chronic illness, and patient outcomes for adults living in a community setting. While VC has been found to be feasible and effective, a low number of randomized controlled trials limit evidence. In addition, studies in this review were not designed to address the question of whether access to care in rural areas is improved through VC. Hence, more research is needed.

Self-efficacy for managing hypertension and comorbid conditions

BACKGROUND Self-efficacy is defined an individual’s belief in completing necessary actions to achieve the desired goal.For individuals with hypertension and other chronic conditions,self-efficacy has been an essential factor to predict adherence to treatment behaviors.AIM To examine self-efficacy for managing chronic conditions in individuals with hypertension.METHODS A total of 1087 individuals with chronic conditions in two groups(hypertension and non-hypertension groups)were selected in this study.The two groups’selfefficacy for managing chronic conditions were investigated using the five domains of patient reported outcomes measurement information system selfefficacy for managing chronic conditions measures(PROMIS-SE);daily activities,emotions,medication and treatment,social interactions,and symptoms.Also,the relationships between self-efficacy and other health-related outcomes for the hypertension group were examined using structural equation modeling.RESULTS Among 1087 participants,437 reported having hypertension.The hypertension and non-hypertension groups were statistically different in self-efficacy for managing daily activities[F(1,598)=5.63,P<0.05].Structural equation modeling indicated that for individuals with hypertension,two domains of PROMIS-SE(managing daily activities and emotions)significantly predict global physical health(P<0.001 and P<0.01 sequentially),and one domain(managing emotions)significantly predicts mental health(P<0.001).Hypertension patients’general quality of life was significantly predicted by global physical health(P<0.001)and mental health(P<0.001).CONCLUSION The hypertension group reported deficits in self-efficacy in managing daily activities as compared to the non-hypertension group.In this hypertension group,self-efficacy functioned as an indirect predictor of general quality of life,mediated by global physical and mental health.

Individual factors related to chronic condition in Portuguese adolescents: Highlights from the HBSC/WHO study

Background: Adolescence includes a period (10 to 19 years) of profound biopsychosocial changes, constituting potentially difficult challenges, which may become more pronounced in the presence of a chronic condition and its limitations. Responses are not homogeneous and can be quite variable, depending on various specific individual factors. Research comparing adolescents with or without chronic illness, or comparing across different conditions, has been contradictory, not confirming a direct relationship between the degree of suffering and the chronic condition. Objective: To characterize and assess the impact of 1) having a chronic condition (CC) and 2) how CC affects school participation;and its association with life satisfaction and perception of wellness, controlling for demographic factors: age, gender and family socioeconomic status (SES). Methods: 5050 Portuguese adolescents with an average age of 14 years participated in the Health Behaviour in School-aged Children/WHO (HBSC). Results: The majority of the adolescents with CC reported that their conditions did not affect school participation. Adolescents with CC who indicated that CC affected school participation felt more frequently unwell and presented lower life satisfaction. Being a boy, younger and having high family socio economic status (SES) were identified as predictors of higher life satisfaction;on the other hand, being a girl, older, having lower SES, living with CC and feeling that CC affects school participation are predictors for feeling more frequently unwell. Conclusions: These adolescents showed an increased vulnerability, presenting internalized symptoms and lower life satisfaction. Furthermore, when there was simultaneous occurrence of living with CC and that CC affected school participation, the impact was even higher. Thus, it is crucial that future interventions should include the identified predictors, combined with “listen to the voice” of adolescents, throughout the adaptation process.

A Comparative Assessment of Disability Levels among Nigerian Outpatients with Schizophrenia and Type 2 Diabetes Mellitus

Background: Chronic illnesses are often associated with functional disability, thus compromising the ability to carry out everyday activities of daily living. The degree of disability depends on the severity and the type of illness experienced. Studies that compare the level of disability between people with chronic medical conditions and mental illnesses in North-Central Nigeria are scarce. This study aims to compare the disability levels between people with schizophrenia and Type 2 Diabetes Mellitus (T2DM) attending outpatient clinics at the Jos University Teaching Hospital, north-central Nigeria, and evaluate the factors associated with these conditions. Methods: It was a cross-sectional study with a total of 600 patients who were diagnosed with schizophrenia and T2DM, attending the Psychiatric and medical outpatient clinics of the Jos University Teaching Hospital, north-central Nigeria, between June 2017 and November 2017. The study assessed Psychotic and non-psychotic symptoms by applying the Brief Psychiatric Rating Scale (BPRS) among those with schizophrenia. We evaluated the level of disability by using World Health Organization Disability Assessment Schedule version 2.0 (WHODAS 2.00). Results: Disability was significantly higher among respondents with schizophrenia than those with T2DM. This difference occurred across all the domains except domain 2 (moving around). Marital status, living situation, occupation, and treatment adherence were significant common factors associated with disability in these conditions. In contrast, age, educational status, income level, and duration of illness were significantly associated with disability among respondents with T2DM only. Conclusion: Disability and its associated factors among people with chronic diseases, if identified early and proper interventions instituted, disability can be avoided or minimized among people with chronic illnesses.

Cardiovascular Risk in Adults and its Association with Health Services Utilization. ENSANUT 2018-2019

Background The use of health services by the adult population is related to cardiovascular risk and its stratification. Cardiovascular risk (CVR) stratification should be a tool for the assessment of the patients and the appropriate control during the process of medical care and utilization of health services for the adults. Objective Evaluate the association between cardiovascular risk (CVR) in adults and the utilization of health services. Material and Methods A secondary analysis was performed of the data from the National Health and Nutrition Survey (ENSANUT) 2018-2019. The CVR classification (risk score) was obtained in 43,070 adults with a previous diagnosis (self-report) and 1,237 adults newly diagnosed. Independent, risk factors and the association between groups of CVR and utilization of preventive, outpatient and hospital services were analyzed. Results More than 85% of adults interviewed have some degree of CVR. Almost half of them have low CVR (48.2%). Older adults with social security predominate in the group with high and very high CVR. Seventy-five percent of adults recently diagnosed have low CVR. In both, there is very little utilization of health services. For adults previously diagnosed CVR, the higher the CVR, the greater the likelihood of utilization of outpatient, preventive and hospital services, in contrast to adults without CVR independent of the marital status, sex, health institution and socioeconomic level. Conclusion The results give evidence of areas of opportunity for improvement in the quality of health services. The evaluation of CVR in primary care and promotion and prevention of CVR should be strengthened.

How are children with medical complexity being identified in epidemiological studies?A systematic review

Background There are different definitions to identify/classify children with medical complexity(CMC).We aimed to investigate and describe the definitions used to classify CMC in epidemiological studies.Methods PubMed,SciELO,LILACS,and EMBASE were searched from 2015 to 2020(last updated September 15th,2020)for original studies that presented the definition used to classify/identify CMC in the scientific research method.We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology.From the included studies,the following were identified:first author,year of publication,design,population,study period,the definition of CMC used,limitations,and strengths.Results Nine hundred and sixty-seven records were identified in the searched databases,and 42 met the inclusion criteria.Of the 42 studies included,the four most frequent definitions used in the articles included in this review were classification of CMC into nine diagnostic categories based on the International Classification of Diseases,Ninth Revision(ICD-9)(35.7%,15 articles);update of the previous classification for ICD-10 codes with the inclusion of other conditions in the definition(21.4%,nine articles);definition based on a medical complexity algorithm for classification(16.7%,seven articles);and a risk rating system(7.1%,three articles).Conclusions CMC definitions using diagnostic codes were more frequent.However,several limitations were found in its uses.Our research highlighted the need to improve health information systems to accurately characterize the CMC population and promote the provision of comprehensive care.