SMILE 2 – To Test the Integrated Virtual and Specialist Care of Multimorbid Chronic Disease Patients

The SMILE2 project centres on integrated virtual case management of patients with multimorbid chronic disease in the community, to support them to live more independently and reduce their episodes of deterioration. The project is a joint initiative between the Health Service Executive’s Enhanced Community Care programme together with specialist chronic disease ambulatory hubs partnering with Caredoc, and is aligned to the National Model of Care for Chronic Disease. The virtual nature of the project addresses the capacity of the Health Service to deliver targeted and integrated case management services in an efficient way. The focus of the project is virtual case management by trained triage nurses combined with remote patient monitoring. Its design is based on the integration and expansion of the established SMILE1 service with the ambulatory care hubs so that the learnings and support from SMILE1 can be utilised and maximised to further strengthen patient outcomes, and enable scale up. SMILE2 is funded by the Slaintecare Integration Innovation Fund and enables remote health monitoring via wearable connected devices, by collating healthcare data generated by participants for ongoing nurse-led triage review. The implementation of the project involves experienced Caredoc triage nurses working in partnership with the newly recruited chronic disease hub Clinical Nurse Specialists to identify and stratify patients from the population that need more intensive case management support and tailor care to each participant and their specific needs. The objective of this is to prevent deterioration in patient conditions and empower participants with the knowledge for proactive self-management of their health. This is achieved using monitoring equipment that provides real-time information to the patient as well as to triage nurses overseeing their healthcare data. Thresholds set for patients trigger alerts when a reading is out of range, prompting a call to the patient from a triage nurse to investigate and if necessary, liaise with the patient’s hub-based chronic disease specialist staff for review and to agree the appropriate steps to be taken. This allows for early intervention and prevention of further exacerbation of a patient’s condition, as well as decreasing the likelihood of the patient requiring an unscheduled Emergency Department visit. This process ensures that care is person-centred and supports patients to proactively self-manage, leading to improved patient outcomes. In tandem with this, patients receive educational support from the triage nurses around their conditions, which will increase their knowledge of factors that affect their health, enabling them to make positive changes in their lives. The use of virtual technology for monitoring and patient engagement allows an efficient and cost effective use of nursing resources, allowing larger case loads, as patients with complex conditions and associated needs receive engagement at the intensity they require. The integration of the SMILE service with the chronic disease hubs also facilitates potential scaling up of the project throughout the country, as it also enables efficient use of HSE specialist clinical staff.