Taking virtual care beyond single diseases: a new approach for patients with complex health needs
As SPHERE celebrates 10 Years of Impact, we're showcasing some of the initiatives that have grown from SPHERE support into projects working to improve patient care and the health system. One of these is a virtual health project, co-led by Professor Nigel Lovell from UNSW’s School of Biomedical Engineering and the Tyree Foundation Institute of Health Engineering (IHealthE), and Prof Sze-Yuan Ooi from Prince of Wales Hospital. The project is tackling an increasingly important challenge: how to provide better care at home for people living with multiple chronic health conditions.
For many patients with chronic disease, healthcare does not fit neatly into a single diagnosis. They may be managing heart disease alongside mobility problems, rehabilitation needs or other conditions, while moving between hospital, home-based services and ongoing care.
Yet many digital health programs have traditionally been designed around individual diseases.
A multidisciplinary team led by Professor Lovell and Professor Ooi is working with South Eastern Sydney Local Health District (SESLHD) to develop a different approach.
With $200,000 through SPHERE's 2024 Seed Funding Partnership Grant Scheme, the team is developing TCC-360, a more flexible version of the original TeleClinical Care (TCC) platform designed to support people with complex chronic comorbidities rather than a single condition.
TCC combines a patient smartphone app with a secure clinician portal and connects with the hospital electronic medical record. Earlier versions of the platform have been tested in cardiovascular disease and stroke and used to support patients with heart failure and COVID-19.
The new project takes the technology a step further by integrating TCC-360 with SESLHD's Community Management Centre (CMC) and established Hospital in the Home services.
The aim is to create a model in which patients can receive more personalised monitoring and care in the community, while clinicians have the information and systems they need to manage that care as part of their existing clinical workflow.
Professor Ooi said designing the platform around patients with multiple conditions was an important progression from earlier disease-specific applications.
"Patients don't experience their health conditions in isolation. Many people are living with several chronic conditions at the same time, so we need models of virtual care that can respond to the whole person rather than focusing on one disease. TCC-360 is about creating a more flexible and personalised approach that can support those patients while connecting their care across hospital, home and virtual services."
Importantly, the technology is not being developed in isolation and then handed to health services to implement.
The project is being co-designed with clinicians and other stakeholders from SESLHD and Hospital in the Home services at Prince of Wales, St George and Sutherland hospitals. Implementation science experts are also working with the team to identify how TCC-360 can be successfully incorporated into routine care.
This focus on implementation is central to the project. Rather than simply asking whether the technology works, the team is examining how virtual care can work within health services, how clinicians and patients experience it, and how hospital-based, home-based and virtual care can be better connected.
SPHERE funding has also allowed the researchers to bring forward plans to integrate NeuRA's StandingTall exercise program into the TCC platform, work that had originally been planned for a later phase of the project.
The integration will contribute to the development of TCC-Rehab, extending the platform beyond monitoring to support virtual closed-loop rehabilitation and secondary prevention.
Professor Lovell said SPHERE's support had helped the team expand the scope of the work and bring together expertise from across research and healthcare.
"SPHERE funding has enabled us to bring together the clinical, technology and implementation expertise needed to design this around the way care is actually delivered through a careful co-design process. It has also allowed us to bring forward the integration of StandingTall, so we can start looking beyond remote monitoring to how virtual care can also support rehabilitation and prevention."
The project brings together expertise spanning biomedical engineering, cardiovascular health, ageing, implementation science and health economics, with researchers and clinicians from UNSW, SESLHD, NeuRA and The George Institute for Global Health.
Although the project is still in its early stages, the team has established its governance and project plan, secured ethics and site approvals, begun stakeholder engagement and undertaken multidisciplinary work to better understand the needs and gaps in remote patient monitoring.
The work is also contributing to a broader program of research into virtual care. The team has secured additional funding through an ARC Industry Transformation Research Centre project, with $500,000 in matching ARC funding to continue the development of TCC-360 and TCC-Rehab. A related project using the TCC platform with Geriatric Outreach Services has also received $2.33 million through the MRFF Dementia, Ageing and Aged Care Mission.
The longer-term goal is to develop an approach that can extend beyond individual hospitals and individual diseases. By designing the technology around the realities of caring for people with multiple health conditions, and embedding implementation into the project from the beginning, the researchers hope to establish a model that can eventually be scaled more widely.
As one of SPHERE's 10-year stories, the project also demonstrates how research translation continues to evolve. A platform built through years of research is now being brought together with health services, implementation expertise and other SPHERE-supported innovations to explore how more care can be delivered safely and effectively beyond the hospital walls.