Clinical Trials Logo

Clinical Trial Summary

In Canada, 3 out of 4 Canadians aged 65 and older have at least one chronic condition, while 1 in 4 seniors reported having three or more. Caring for complex patients who usually have multiple chronic conditions (MCC) is one of the biggest challenges facing our healthcare system. For patients, the lack of coordination and continuity of care as they transfer between healthcare settings and healthcare providers (HCPs) often results in a higher risk of readmission, suboptimal and fragmented care plans, delays in required medical intervention, inadequate self-care, and confusion on whom they should contact when they have questions. For the patient's care team, they often have no indication how patients are doing between clinic visits unless the patient can provide a log of their home measurements (e.g., blood pressure). Therefore, they are unable to detect and intervene if their patient's health is worsening between visits. In order to address this increasing need to bridge the current gap in clinical management and self-care of complex patients during their transition from healthcare settings to home care, our team aims to design, implement and evaluate the SMaRT (Safe, Managed, and Responsive Transitions) Clinic, a nurse-led integrated care model facilitated by telemonitoring (TM). Specifically, the SMaRT Clinics aim to meaningfully introduce a nurse (or nurse practitioner) role to improve clinical coordination across patient care teams and reinforce proper self-care education through the use of telemonitoring. This project will be conducted in two phases across four years; Phase I: Design and Development, and Phase II: Implementation and Effectiveness Evaluation. Phase II research activities include enrolling 350 patients with complex chronic conditions in the SMaRT clinics across four study sites. The implementation and effectiveness of the SMaRT clinics will be evaluated through a mix of semi-structured interviews, ethnographic observation, patient questionnaires, and analyses of health utilization outcomes using propensity-matched controls from the ICES provincial database.


Clinical Trial Description

The overall objective of this study is to design, implement, and evaluate SMaRT Clinics at four hospitals across Ontario serving complex patients transitioning home from the hospital in urban, suburban and rural settings. Instead of developing new technology for the nurse-led SMaRT Clinic, an existing validated TM system that is able to monitor patients with multiple chronic conditions, named Medly, was chosen. Medly was developed at eHealth Innovation (now called the Centre for Digital Therapeutics), UHN and was designed to monitor a medley of chronic conditions, and has been evaluated in trials for single chronic conditions and multiple chronic conditions. For the purposes of this trial, Medly will enable the TM of heart failure, COPD, diabetes, hypertension, and depression. The patient-facing technology includes the Medly smartphone application (app). The app enables patients to complete symptom surveys and record physiological measures using peripheral devices relevant to their chronic condition (e.g., weight scale, blood pressure monitor, and/or blood glucose monitoring). Designed as a modular app, features and parameters to be monitored can be added and removed, and target values for each parameter (e.g. blood pressure) can be individualized according to the needs of each patient. The inputted measures are processed by an embedded rules-based algorithm (customized to the patient by the setting of target thresholds) which triggers appropriate self-care messages being displayed to the patient within the app (e.g., instructing patients to take their prescribed medication, informing patients to contact their care team, etc.). Other features of the Medly app include the ability to view a historical record of their inputted readings, view graphical trends of blood glucose and blood pressure values, and to assist with adherence, an automated phone call to remind patients if they have not yet taken their readings by the appropriate time for their condition. The clinician-facing technology includes the Medly dashboard. To support clinical decision-making, clinicians are alerted to clinically significant changes to patient health status and are able to assess alerts generated by the embedded algorithm and review patient data, including which parameters triggered the alert, prescribed medications, graphical trends of lab results and relevant measures, and contact information. Clinicians may also be informed of triggered alerts through email notifications. Information presented on the Medly dashboard may be leveraged to inform clinical decision-making throughout the patient's follow-up care journey. ;


Study Design


Related Conditions & MeSH terms


NCT number NCT05543720
Study type Interventional
Source University Health Network, Toronto
Contact Emily Seto, PhD
Phone 416-669-9295
Email emily.seto@utoronto.ca
Status Recruiting
Phase N/A
Start date October 17, 2022
Completion date September 2025

See also
  Status Clinical Trial Phase
Terminated NCT04591808 - Efficacy and Safety of Atorvastatin + Perindopril Fixed-Dose Combination S05167 in Adult Patients With Arterial Hypertension and Dyslipidemia Phase 3
Recruiting NCT04515303 - Digital Intervention Participation in DASH
Completed NCT05433233 - Effects of Lifestyle Walking on Blood Pressure in Older Adults With Hypertension N/A
Completed NCT05491642 - A Study in Male and Female Participants (After Menopause) With Mild to Moderate High Blood Pressure to Learn How Safe the Study Treatment BAY3283142 is, How it Affects the Body and How it Moves Into, Through and Out of the Body After Taking Single and Multiple Doses Phase 1
Completed NCT03093532 - A Hypertension Emergency Department Intervention Aimed at Decreasing Disparities N/A
Completed NCT04507867 - Effect of a NSS to Reduce Complications in Patients With Covid-19 and Comorbidities in Stage III N/A
Completed NCT05529147 - The Effects of Medication Induced Blood Pressure Reduction on Cerebral Hemodynamics in Hypertensive Frail Elderly
Recruiting NCT06363097 - Urinary Uromodulin, Dietary Sodium Intake and Ambulatory Blood Pressure in Patients With Chronic Kidney Disease
Recruiting NCT05976230 - Special Drug Use Surveillance of Entresto Tablets (Hypertension)
Completed NCT06008015 - A Study to Evaluate the Pharmacokinetics and the Safety After Administration of "BR1015" and Co-administration of "BR1015-1" and "BR1015-2" Under Fed Conditions in Healthy Volunteers Phase 1
Completed NCT05387174 - Nursing Intervention in Two Risk Factors of the Metabolic Syndrome and Quality of Life in the Climacteric Period N/A
Completed NCT04082585 - Total Health Improvement Program Research Project
Recruiting NCT05121337 - Groceries for Black Residents of Boston to Stop Hypertension Among Adults Without Treated Hypertension N/A
Withdrawn NCT04922424 - Mechanisms and Interventions to Address Cardiovascular Risk of Gender-affirming Hormone Therapy in Trans Men Phase 1
Active, not recruiting NCT05062161 - Sleep Duration and Blood Pressure During Sleep N/A
Not yet recruiting NCT05038774 - Educational Intervention for Hypertension Management N/A
Completed NCT05087290 - LOnger-term Effects of COVID-19 INfection on Blood Vessels And Blood pRessure (LOCHINVAR)
Completed NCT05621694 - Exploring Oxytocin Response to Meditative Movement N/A
Completed NCT05688917 - Green Coffee Effect on Metabolic Syndrome N/A
Recruiting NCT05575453 - OPTIMA-BP: Empowering PaTients in MAnaging Blood Pressure N/A