Development and Evaluation of a Nurse-Led Telehealth Care Coordination Model

Thesis Abstract

This study addresses the rising fragmentation of care for patients with chronic conditions by developing and evaluating a nurse-led telehealth care coordination model designed to enhance continuity, accessibility, and outcomes in primary care. Persistent gaps in care coordination, limited access to timely follow-up, and variable patient engagement contribute to avoidable hospitalizations and diminished quality of life. The aim is to design, implement, and evaluate a scalable telehealth care coordination model led by registered nurses, incorporating structured protocols, patient activation, and interprofessional collaboration to improve care continuity and health outcomes. Specific objectives are to (1) design a nurse-led telehealth care coordination protocol grounded in the chronic care model and evidence-based care transition strategies, (2) evaluate feasibility, fidelity, and acceptability of the model among patients, caregivers, and primary care teams, (3) assess effects on service utilization, disease-specific outcomes, and patient-reported quality of life, (4) identify barriers and enablers to implementation, and (5) develop a replicable framework for broader adoption. A mixed-methods design integrates a quasi-experimental controlled trial with a concurrent qualitative process evaluation. The population comprises adults aged 40–75 years with at least one chronic condition (diabetes, hypertension, or chronic obstructive pulmonary disease) managed in urban primary care clinics. A sample of 320 patients will be recruited and allocated to intervention (n=160) and standard care (n=160) groups using matched clinic pairs. The nurse-led intervention includes weekly telehealth check-ins for three months, monthly follow-ups for an additional three months, risk-stratified care plans, medication reconciliation, self-management coaching, and facilitated communication with physicians and allied health professionals. Data collection instruments include validated measures the Patient Activation Measure (PAM), EuroQol-5D-5L (EQ-5D-5L) for quality of life, the 12-Item Short Form Survey (SF-12), the Charlson Comorbidity Index, hospitalization and emergency department utilization records, and process measures of fidelity and patient satisfaction. The study will employ intention-to-treat analysis. Quantitative analysis consists of descriptive statistics, repeated-measures ANOVA to compare changes over time between groups, negative binomial regression for healthcare utilization, and multilevel modeling to account for clustering by clinic. Mediation analysis will explore whether changes in patient activation mediate outcomes. The qualitative component uses thematic analysis of semi-structured interviews with 40 patients, 20 caregivers, and 20 clinicians, guided by the Normalization Process Theory and the Chronic Care Model to elucidate integration processes, acceptability, and contextual factors influencing implementation. Data sources will include electronic health records, telehealth encounter logs, and survey instruments. Anticipated findings include improved patient activation, higher quality of life scores, and reduced 6- and 12-month hospitalization rates in the intervention arm compared with standard care. It is expected that the model will demonstrate higher patient satisfaction and better adherence to care plans, with enhanced interprofessional collaboration and smoother care transitions. The study will contribute to knowledge by providing rigorous evidence on the effectiveness and implementation determinants of nurse-led telehealth care coordination in diverse primary care settings, detailing scalable components, resource implications, and integration strategies with electronic health records. The theoretical contribution will map empirical outcomes to the Chronic Care Model and Normalization Process Theory, clarifying how nurse-led telehealth can operationalize patient-centered, proactive care in chronic disease management. Based on findings, the study will offer recommendations for policy and practice, including resource allocation for telehealth infrastructure, standardization of nurse-led care coordination protocols, training curricula focusing on telecommunication competencies, and governance models for interprofessional collaboration. Limitations include potential selection bias, variation in clinic practices, and the generalizability of urban settings to rural contexts. If successful, the model could be scaled to national primary care networks with adaptations for population needs, fostering sustainable improvements in chronic disease management through nurse-led telehealth care coordination.