Patient empowered monitoring in patients with heart failure and kidney disease at high risk of hospital readmission.

Intervention: patient self monitoring of biometrics in combination with a phone application with digitised fluid management plan and hospital support. A program involving daily home monitoring of biometrics using a smart watch, Bluetooth scales and Bluetooth blood pressure machine. This will be paired with a phone application developed by Sicura Health with a fluid module activated. Biometric parameters will be set by the medical team. When outside set parameters feedback from the phone app is provided to the patient in the form of alerts, for example if a patient's weight has gone up by 2kg they will receive an alert to increase their diuretic medication. Each parameter blood pressure, heart rate and weight are individualised to the patient. Alerts range from instructing the patient to enact their self-management plan, through to critical red alerts requiring them to seek urgent medical attention. Patients will be encouraged to monitor daily for the 6 month duration of the trial. The blood pressure cuff is applied to the upper arm and links directly with the phone application. Participants will asked to measure their blood pressure each morning, by taking three readings. They will be asked to step on the weight scales when they wake up in the morning. They are asked to wear the SmartWatch every day, around the wrist. The team recommends wearing it at all times except in the shower or swimming. When patients are enrolled they will be provided with an education session that sets up the phone application and ensures it is connected to the blood pressure cuff, smart watch and scales. They will also be shown how to use the devices. Adherence to the intervention will be monitored by reviewing a log of records (for example blood pressure, weight, heart rate). Patients who are not using the intervention will be called and offered review to assist them with any difficulties. If despite addressing any issues, they are still unable to participate in monitoring they will withdrawn from the study. The fluid management plan is part of standard of care for patients with heart failure and kidney disease, and individualised to the patient. As part of standard care this is provided in written format with instructions to increase diuretic based on a weight increase. For this trial this will be digitalised and include weight, blood pressure and heart rate parameters. Only change in weight will trigger the alert to increase diuretic dose. Blood pressure and heart rate parameters being out of individualised range (e.g. HR 120) will trigger an alert for the patient call the hospital 24hour nursing number. This model will be integrated into existing workflows to enable timely community care. This includes a 24 hour nursing hospital number (this is already provided to patients with complex care needs) that patients can ring if alerted to. This leads to a triage process of phone advice, visiting a general practitioner, a rapid home assessment (within working hours), a rapid access specialist outpatient appointment or a recommendation to seek emergency assistance.