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Experiences from using telemonitoring as a tool for patient care delivery in the community – A hands-on approach


Vicki Bonfield ,

South Western Sydney Local Health District, NSW, AU
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Veronica Gonzalez-Arce,

South Western Sydney Local Health District, NSW
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Jenny Ly

South Western Sydney Local Health District, NSW, AU
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Introduction: Wollondilly LGA is a peri-urban region in south-west Sydney with a population of approximately 48,000. A health needs assessment of the area identified Chronic Obstructive Pulmonary Disease (COPD) was the main chronic disease for frequent Emergency Department (ED) presentations and hospital admissions. In addition, there were limited health specialists, no local hospital and no after-hours health services; and a GP:patient ratio of 1:2,723 (national benchmark 1:1,100).

Practice change: Telemonitoring was identified as a strategy to address the needs assessment concerns. An individualised telemonitoring care plan is co-designed with the patient’s GP. At home, patients/carers monitor vital signs and health conditions via peripheral devices and individualised health interviews. All management decisions are made in partnership with their GP for clinical governance.

Aim: The telemonitoring program aims to facilitate coordinated care delivery through closer collaboration between the patient/carer, treating GP, LHD community services and disease-specific specialist/team. As well as improve support and rapid access to care in the community, manage multi-morbidities, encourage self-management, increase health literacy—disease signs and symptoms—and improve clinical outcomes.

Population: The original cohort for the telemonitoring project in Wollondilly were advanced stage COPD patients.

Timeline: Established in 2015 and sustained since.


• Improved patients’ understanding of their condition

Patients involved in their own care and over time have better identified their risk status. Patients are able to better recognise symptoms of their condition and know what to do to self-manage. With confidence that patients can self-manage at home, the program has reduced carer burden, enabling them to undertake activities outside the home (e.g. shopping).

• Patients’ needs are identified, assessed and managed in a caring, effective manner meeting patients’ needs

This is the first telemonitoring program in NSW that has implemented patient reported experience measures (PREMs). PREMs outcomes demonstrate that the program improved quality of life, increased patient confidence to self-manage their chronic condition, and enabled timely, easy to understand information or advice from health professionals.

• Reduced hospital admissions and length of stay (LOS)

Chronic disease-related hospital admissions have decreased by 35% and LOS for chronic disease have decreased by 34% based on a year-to-date comparison to June 2019.

Sustainability/Transferability: The telemonitoring model of care has been successfully expanded to other LGAs in South Western Sydney. It now also includes other chronic conditions, such as heart failure and diabetes.

Telemonitoring transitioned as part of the Primary and Community Health suite of care delivery through the Integrated Care for Patients with Chronic Conditions program.


• Need for greater communication between client/patient, carer, Telemonitoring Clinical Coordinator and GP

• Increased GP engagement between a patient and their usual GP

• Role of the Telemonitoring Clinical Coordinator as essential to enable appropriate referrals to the program and ongoing care support.

• Suitability of cohort (to include patients at earlier stages of chronic conditions) for a sustainable initiative.

Conclusion: This model of telemonitoring provides a patient-focused approach with the GP as key stakeholder and integration across different sectors of the health system.

How to Cite: Bonfield V, Gonzalez-Arce V, Ly J. Experiences from using telemonitoring as a tool for patient care delivery in the community – A hands-on approach. International Journal of Integrated Care. 2021;20(S1):108. DOI:
Published on 26 Feb 2021.


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