Telemonitoring process

Steps in telemonitoring process

  • Patient selection

    Trust and primary care health & social care professionals can identify patients whom they would consider suitable to receive telemonitoring services. Patients may be recently diagnosed or may have had a long term condition for a period of time.

    Telemonitoring may be used:

    • As an aid to diagnosis
    • As a short term intervention (3/6/9 months) to encourage better self management.
    • To provide an additional level of support to patients on either a short or long term basis

    Generic referral criteria have been identified as have specific criteria for CHF/CHD, COPD, diabetes and stroke.

  • Referral

    Healthcare professionals can refer patients by completing and submitting a patient plan via an online referral form.

    When referring, healthcare professionals can indicate at which stage the patients ongoing need for telemonitoring should be reviewed and the parameters which should apply to the assessment of vital signs.

    Once the relevant information to refer a patient has been collected, completion of the online referral takes approximately 20 - 30 minutes.

    Online referrals need not be completed in one sitting – partially completed forms can be saved and returned to on another occasion

  • Consent

    Prior to making a referral, healthcare professionals should ensure that patients are fully informed about the service and how it will operate for them. Patient’s verbal consent to be referred should be obtained.

    TF3 will obtain patient consent at other relevant stages when progressing the referral. For example, consent to have equipment installed, consent to submit electronic data and for TF3 to review and store such data.

  • Installation

    Upon receipt of the patient plan TF3 will contact the patient to arrange for the installation of the equipment in their home.

    Urgent referrals will be completed within 20 working hours of referral.

    Standard referrals will be completed within 48 working hours of referral (this may be extended to 80 working hours with the approval of the patient or carer).

  • Training

    Healthcare professionals who want to receive training in the Telemonitoring NI service should contact their trust’s designated Telehealth Service Manager

    Full training in the use of equipment is provided to patients by TF3 at the time of installation and a support desk provides further support to them as required.

  • Monitoring

    Clinical Triage

    Healthcare professionals may determine in conjunction with patients the frequency with which patients take their readings (usually once per day) and the time of day at which they are taken.

    Patients will:

    • upload their readings, generally on a daily basis or as specified by their healthcare professional;
    • answer pre-set questions (if any) requiring 'YES' or 'NO' answers on their symptoms and wellbeing as requested by their healthcare professional;
    • measurements will be transmitted to the TF3 monitoring centre where they will be reviewed against pre-set parameters.

    Track and Trend

    Healthcare professionals may determine in conjunction with patients, the frequency in which patients take their readings and the frequency in which they are uploaded (which may be multiple times per day and may be uploaded periodically, e.g. weekly).

    Patients will:

    • continue to be monitored by their healthcare professional and will not be triaged by the TF3 triage team;
    • only be contacted if they do not take their readings, take partial readings or there is a technical fault with the equipment.
  • Triage process

    Clinical Triage

    The patient’s measurements will be collected and transmitted to the TF3 monitoring centre where they will be reviewed against the parameters which have been set for that patient. Where measurements fall outside of the parameters a member of the TF3 triage nursing team will contact the patient by phone in order to provide relevant information and support.

    Where the patient’s reading is significantly outside of patient’s alert limit, the triage process is to be completed within two working hours of receipt of patient’s reading where it is except where the reading is received after 1pm when the triage process is to be completed by 11am on the next working day.

    Where the patient’s reading is marginally outside of patient’s alert limit, the triage process is to be completed within four working hours of receipt of patient’s reading except where the reading is received after 1pm when the triage process is to be completed by 1pm on the next working day.

    Track and Trend

    Not applicable

  • Responding to alerts

    Clinical Triage

    Following this, and where it is deemed appropriate by the triage service, the designated local response team within each trust will be contacted. The local response team will determine what, if any, further action is required.

    Any escalation of breaches of patient’s alert to trust local response services will be carried out within 30 minutes during work hours.

    Track and Trend

    Not applicable

  • Review and discharge

    Three weeks before the patient’s period of telemonitoring is due, the healthcare professional will receive an email reminder to carry out a review of the patient’s progress on telemonitoring. Based on the patient information and the objectives set for referring the patient on telemonitoring, the healthcare professional will make an assessment whether the patient should continue on telemonitoring or be discharged.

    Upon notification of a discharge, TF3 will contact the patient in order to arrange a suitable date for the uplift of the equipment.