HOW IT WORKS
Initially targeting elderly people living at home, the National Program for Personal Connected Health and Care (PCH) now aims to improve patient safety for adults who have multiple chronic illnesses or complex medical conditions. The program equips patients with remote-care assistance and other technologies to enable them to monitor and manage their health and well-being. Patient data are transmitted to a support service staffed by specially trained nurses. If the collected data indicate inconsistencies, service-response staff contact the patient to investigate further. Primary care contact depends on the patient’s condition; if the patient can manage technology, can self-monitor, and feels secure, home care services are accessed as needed. Otherwise, home care nurses visit daily.
During the its first phase (2015–2018), the national program elected and established four pilot sites based on applications from these municipalities. The second phase (2018–2020) will be a randomized controlled trial that will include pre- and post-intervention data. Since 2015, the program has enrolled 822 patients; 600 more will participate in the second phase. Results from an evaluation of the first phase are available in Norwegian. That initial evaluation reports that users sense increased follow-up and improved control of their own health.
For providers. In the next phase, providers will participate in structured, multidisciplinary care team meetings. They will work with one integrated team or as part of different teams working collaboratively. GPs are responsible for most of the program’s patients and manage them as part of their wider caseload. In program phase 1, nurses were responsible for taking comprehensive histories and conducting assessments of health and social care needs. In phase 2, focusing on remote care, GPs will take on more responsibility for the majority of program intake and assessment.
For patients/caregivers. Patients monitor their own condition, and patients and their caregivers identify and record goals in an individualized care plan.
The Norwegian Directorate of Health is responsible for service development and dissemination together with KS, the interest organization for the municipalities. A wide range of other stakeholders are involved in program delivery and staffing, ranging from local federations of municipalities to the Norwegian Directorate of eHealth. The program organization also has a wide range of local and regional partners, all of whom have project management roles. This program involves regular communications, knowledge translation, and reporting meetings with the health ministry.
Data-sharing is a high priority. There is a long-term national objective to establish a “one citizen with one record/EMR” practice for all municipalities in Norway. The program adjusts to improvements in service quality, eligibility rules, and cost-effectiveness. Public grants help notify providers about the program.
Contact: Thor Steffensen, Program Manager
Additional information on program impact: Good User Experiences with Medical Distance Follow-Up, https://helsedirektoratet.no/nyheter/gode-brukererfaringer-med-medisinsk-avstandsoppfolging