safe@home: effectiveness and cost effectiveness of telemonitoring and virtual care supported by primary care for people living with chronic disease in low socioeconomic neighbourhoods on ambulance ramping, readmission and GP clinic bloc

After randomisation, the Northern Adelaide Health Network (NALHN) safe@home telehealth nurses will inform intervention group participants that a telemonitoring and self-care kit will be delivered to their home and set-up and initial training will be conducted by video call through the tablet included in the kit which contains easy-to-use monitoring, analysis and communication technology, including a touch-screen tablet with tutorial videos on how to use the telemonitoring system which include various tools for monitoring vital symptoms and signs via blue tooth (pulse oximetry, blood pressure monitor, glucometer, thermometer, scale). The communication technology has been previously developed and applied for telemonitoring of chronic diseases for people living in rural areas in Australia by the Integrated Cardiovascular Clinical Network (iCCnet SA), a branch of the South Australian Department of Health. The technology can be personalised and has branching and decision support logic to ensure relevance to the patient.Personalisation will occur after baseline data information entered by the patient during the baseline videocall with the nurse. Only questionnaires and education relevant to individual patients will be offered in subsequent assessments. This will make it possible for people to self-monitor and gain immediate test results at the local point of care. The expected duration of the tutorial video is 3 minutes and the complete set-up of the technology 12 minutes. Participants will be encouraged to complete a self-assessment through the technology at least once a week for 12 months. This has an expected duration of 30 minutes and includes: o Physical Activity assessed by steps per day, minutes of moderate or vigorous physical activity per day measured by the International Physical Activity Questionnaire (IPAQ) Short Form and the 6-Minute Walking Test. o Healthy Eating assessed by the Short Food Survey (SFS) Questionnaire o Medication Adherence measured by the Adherence Scale in Chronic Diseases (ASCD) questionnaire o Sleep Apnoea measured by the STOP-BANG questionnaire which has questions about snoring history, tiredness during the day, observed stop of breathing while sleeping, blood pressure, body mass index, age, neck circumference and gender. o Depression measured by the Patient Health Questionnaire (PHQ) 2 and 9 o Anxiety assessed by the Generalized Anxiety Disorder (GAD) 7 Questionnaire o Health Related Quality of Life measured by the European Quality of Life 5 Dimensions 5 Levels (EQ5D-5L) questionnaire The NALHN telehealth nurses will review data entry daily. Nurse support will be available from 9 am to 5 pm daily during the trial, with all patients advised to implement emergency management plans out-of-hours if there is a clinical problem. The service will also provide information technology (IT) support. The NALHN safe@home telehealth nurse will contact the participants by video call 1) For any pre-specified clinical data variation; 2) When data has not been entered for >7 days; and 3) Routine follow-up at 30 days, 90 days, and 12 months. The telemonitoring system is intuitive and automatically triages patients using a red flag system. Telemonitoring variances will activate a traffic light system response system. Green - all measurements normal (no action); Amber - data variances, data queries will have 3 levels of response according to need: 1) Call from the Telemonitoring Nurse, 2) Activation of Better Care Nurse home visit or Telehealth call from GP, 3) Activation of a home visit by Locum GP. RED - call Paramedics.