Older Adults and Healthcare Professional’s Experiences of Telemonitoring in Primary Home-Based Care in Sweden: A Feasibility Study

Introduction

With a rapidly growing older population with chronic conditions, developing effective methods for delivering healthcare services in home-based settings is crucial.^1,2 The World Health Organization (WHO) emphasized the need for care that is coordinated, seamless, and person-centered, as outlined in its 2019 guidelines on Integrated Care for Older People.³

Telemonitoring (TM) has emerged as a promising approach for delivering primary care, evolving from telephone-based remote diagnosis in the 19^th century⁴ to more advanced technologies in the 20^th and 21^st centuries.⁵

TM has played an increasingly prominent role in supporting self-care and improving health outcomes for older adults with chronic conditions, especially over the past decade.⁶ The WHO defines TM as the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies to exchange of valid information for diagnosis, treatment, prevention of disease and injuries, research, evaluation, and continuing education, all in the interest of advancing the health of individuals and communities. (WHO, 1997).

Evidence indicates that various transmission technologies, including home TM, reduce all-cause and cardiovascular mortalities among patients with heart failure and decrease hospitalizations when used for >12 months.⁷ Additionally, TM is effective in managing diabetes, hypertension, and rheumatoid arthritis in older adults with chronic conditions.⁸

However, despite the promising effects of telemedicine, a gap remains between new technologies and traditional practices, posing a significant challenge to integration in practice.⁹ This gap is evident not only in the technological and organizational barriers experienced by both healthcare professionals (HCPs) and patients, but also in the difficulty of aligning digital solutions with principles of person-centered care (PCC). While telemedicine can enhance accessibility, support self-management, and facilitate new forms of interaction,¹⁰ several studies show that digital care may risk reducing opportunities for shared understanding, patient narrative, and relational continuity if not carefully designed and supported.¹¹ Patients with complex needs, low digital literacy, or communication challenges may experience reduced person-centeredness in remote encounters,¹² highlighting the importance of tailoring digital solutions, creating supportive workflows, and ensuring that telemedicine complements, rather than replaces, traditional person-centered practices. Together, these factors illustrate that successful integration requires more than technological adoption; it requires safeguarding the relational and participatory elements that underpin PCC.

Another important aspect to consider when implementing TM is health literacy, defined in this study as the ability to receive, interpret, and act on health information. The promise of improving health literacy through technology has not been fully realized owing to a lack of understanding and challenges in integration.⁹

Additionally, research highlights a gap between access to technological devices and the skills required for their appropriate use. Addressing these skills through doctor-patient consultations can help increase patients interest using telemedicine.⁸

Over the decades, substantial research and resources have been dedicated to facilitating appropriate, timely, and comprehensive care for older adults with chronic conditions.^13,14 Furthermore, self-care continues to be a major area of interest and is defined as the attainment and sustainment of optimal health.¹⁵

In 2020, a project was initiated to evaluate TM use among older adults with chronic conditions. The project was a collaboration between the municipality and county council in a small region in central Sweden. The initial study focused primarily on healthcare professionals (HCPs) and explored their perceptions of facilitators and barriers to TM.¹⁶ Building on these findings, the current feasibility study, further investigates the integration of TM, including patient perspectives.

In this study, TM was defined as a form of remote patient monitoring––an ambulatory, non-invasive digital technology used to collect patient data in real-time and transmit it to HCPs for assessment or self-management.¹⁷

This feasibility study aimed to describe the experiences, perceptions, and clinical implications of home-based TM among older adults with chronic conditions from the perspectives of older adults and HCPs.

Methods

The study was approved by the Swedish Ethical Review Authority (board of Linköping, 2020–06420) and was performed in accordance with the 1964 Declaration of Helsinki.

Design

This feasibility study employed both qualitative and quantitative methods, as recommended for complex interventions.^18,19 Feasibility studies are essential for interventions with multiple components, as they help identify necessary refinements and guide decisions about subsequent evaluation stages. They can assess aspects such as content, delivery, acceptability, and adherence.²⁰

Bowen et al¹⁸ propose a framework consisting of eight feasibility areas: acceptability, demand, implementation, practicality, adaptation, integration, expansion, and limited efficacy. These areas help determine whether an intervention can work, does work, or will work. This study focuses on assessing four of these areas— demand, acceptability, implementation and practicality, to examine whether TM is feasible in real-life settings.

Sample and Setting

HCPs and older adults from two municipalities in central Sweden, where home care was provided by municipal and regional healthcare services, were invited to participate.

The exclusion criteria involved older adults who were unable to complete data collection or those in the palliative stage. Data were collected between January 2023 and February 2024, beginning with a qualitative study to identify facilitators and barriers as perceived by the healthcare team before implementing TM in home-based healthcare.¹⁶

Participants received no compensation for their participation. Written informed consent including consent of anonymized quotes was obtained before commencing the study.

Data Collection

Demographic data from all participants were collected via a study-specific questionnaire at baseline. Healthcare professionals and older adults also answered a survey about their expectations and concerns about TM at baseline and after four months.

Semi-structured interviews with older adults (n=4) were conducted after the 4-month intervention to gain deeper insights into their experiences. The interview guide included six open-ended questions that explored their perceptions and experiences with TM.

Additionally, diaries (n=9) were collected from the HCP, providing day-to-day notes regarding implementation progress throughout the intervention period.

As this study was designed as a feasibility study, the primary objective was to explore the practicality of recruitment, study procedures, and data collection methods rather than to test intervention effectiveness. Therefore, a smaller sample size was considered appropriate.

Intervention

The intervention involved home-based TM for 4 months. TM systems, equipped with sensors for monitoring blood pressure, body weight, physical activity, and oxygen saturation, were tailored to individual needs and installed in participants’ homes by an IT company. Participants were trained to operate the TM systems independently and had access to a telephone support line for any sensor-related issues.

Data Analysis

Descriptive statistics were used to describe the sample characteristics. The qualitative data from the interviews and diaries was analysed using direct deductive content analysis as described by Elo & Kyngäs.²¹ The feasibility of TM was studied according to the description of various aspects of feasibility as described by Bowen et al.¹⁸

First, all interviews were transcribed verbatim. To get a sense of the whole, the transcripts were read several times by authors ML and MA who also did the initial coding. In the next step, the feasibility areas—acceptability, demand, implementation and practicality—were used as predetermined concepts for coding the text. Coding of the transcripts was done by highlighting text describing the feasibility areas. Text describing the four areas were made into categories. According to Bowen et al¹⁸ each feasibility area consists of various aspects. In the next step of the coding, text describing the feasibility aspects were made into subcategories.

Confirmability was supported through detailed documentation of procedures and the use of an established framework. Quantitative data on patient characteristics were analyzed descriptively to complement qualitative findings.

NVivo 12 Plus software was used to support the analysis. HCP diaries were analyzed in a similar manner, though a manual coding schema was used in place of NVivo for this component.

Results

Participants Characteristics

The study included 12 older adults (50% women, mean age 85.3 years) (Table 1) and 21 HCPs (100% women, mean age 45.8 years) (Table 2).

Table 1 Older Adults Self-Reported Characteristics at Baseline

Table 2 Healthcare Professionals’ Self-Reported Demographics

All older adults were Sweden-born, with 58% living alone. Most had more than two chronic diseases. At baseline, 75% reported no expectations of TM, whereas 17% expressed unspecific concerns (Table 1). Most HCPs (57%) were assistant nurses with an average of 20 years of experience. Additionally, 43% had prior experience working with e-health solutions (Table 2).

Demand

Expressed Interest to Use Telemonitoring

At baseline, all healthcare professionals (HCPs) agreed that telemonitoring (TM) was important for ensuring the safety of older adults. At the same time, they expressed concerns that older adults might experience technical difficulties when managing the system. About half of the HCPs where also uncertain about how TM would fit into their existing workflow. Despite these concerns, they felt that TM enhanced both their own and the older adults’ sense of security. Most older adults reported having no expectations of TM, yet they also expressed no hesitation about starting to use it.

Actual Use of the Support Program

Older adults measured their blood pressure every morning and entered the data on a tablet. However, uncertainty arose when the value from the previous day was displayed on the screen, requiring manual adjustment, which many found difficult, resulting in incorrect values being sent or no data being transmitted at all.

Then I went in and pressed blood pressure on the screen, and it showed yesterday’s reading, and that is when I had to adjust and either add or subtract something.

Yeah, but it was not automatic. I thought they said that, but it was not.

Perceived Demand

Overall, HCPs documented that older adults had a positive attitude toward TM and appreciated the opportunity to participate in the study. Managing their health metrics fostered a sense of self-worth and engagement in their care. Some older adults expressed a desire to keep the monitoring equipment after the study, highlighting the perceived value and positive impact of TM.

When asked if they had learned anything new about their health, older adults reported becoming more aware of changes in their health, particularly with body weight and blood pressure, which was described as positive.

Yea, I suppose I have gained some understanding about blood pressure and weight, that is what I have been checking and what has been interesting to me. So that part has been positive.

In contrast, TM could help detect the symptoms of deterioration earlier:

But measuring more makes the chance of finding … yeah, that you see your blood pressure going the wrong way earlier than if you measure it maybe every third month.

However, despite these positive experiences, barriers to engagement were identified. Insufficient information and training on how to use the sensors led to confusion and diminished motivation among older adults. This lack of clarity resulted in some participants distrusting the equipment and choosing to use their personal measurement tools instead.

Older adults had mixed views on continuing TM as part of their care. Some participated out of a general interest in research but a personal need for monitoring, whereas others joined out of curiosity. Additionally, concerns arose about the potential replacement of regular healthcare contacts with TM.

No, not really, since I do not feel that I need it, that, I feel more like a guinea pig, like yea, like I have done my job as a guinea pig.

As it is now, you do not have much contact with the doctor. About once a year. So, if you start this thing, maybe it disappears, all of it.

Acceptability

Perceived Appropriateness and Satisfaction with Telemonitoring

Four of the older adults (57%) reported a fairly negative experience using TM, with 85% (n=6) finding the technology technically challenging Furthermore, TM did not generate concerns among participants, and for most, it did not enhance their sense of security. However, older adults found that TM could improve the sense of security for family members. Most older adults performed measurements independently without assistance; however, three participants were unable to complete any measurements because of technical issues.

Discrepancies emerged between older adults’ and HCPs’ perceptions of TM. Notable differences appeared in responses to four key questions. Overall, 57% of older adults disagreed that TM increased their security, whereas only 9.5% of HCPs disagreed with the necessity of TM for older adults’ safety. All older adults (100%) reported no concerns about TM, and 47% of HCPs reported that TM worried them.

Technical difficulties were noted by 28% of older adults; however, only 9.5% of HCPs believed that older adults would find TM challenging. Additionally, 14% of older adults considered TM unnecessary, compared with 0% of HCPs who shared that view, Table 3.

Table 3 Responses to Assess Older Adults and Healthcare Professionals’ Experiences of TM After the Intervention

Implementation

Effectiveness and Gains of Using TM

HCPs documented several benefits of the TM system, such as detecting weight gain, which prompted timely interventions, including home visits and medication adjustments. Regular monitoring was considered crucial in preventing health deterioration and reducing hospital visits. HCPs observed that TM encouraged self-care and independence in managing health. The ability to monitor health metrics at home fostered a greater sense of control, which was highly valued by HCPs and older adults.

Daily weight measurements were automatically transferred to a caregiver platform.

The weighing has worked; it is actually the only thing that has worked on this device.

However, no participants received functioning sensors for physical activity, which led to disappointment.

I thought it worked once when I was out walking really far, and I thought now I will see how many steps I have walked, but it was zero.

Practicality

Technical Challenges, Management, and Education for Using TM

Several technical issues emerged from the diaries, including incorrect measurements, transmission failures, and equipment malfunctions, particularly with the blood pressure cuff. Additionally, sensors for monitoring oxygen saturation and physical activity, which were initially planned in the study, were not delivered or did not function properly. This limited the scope of monitoring to just body weight and blood pressure. The absence of oxygen saturation monitoring was particularly noted as a shortcoming in this intervention.

The monitoring program required substantial resources regarding nurse visits and follow-ups to address abnormal readings. HCPs and older adults expressed the need for adequate training and support. The older adults reported difficulties in resolving technical issues and experienced delays in installing the sensors. In some cases, interruptions in the monitoring process occurred owing to health deteriorations among older adults, leading to long pauses in data collection and challenges in conducting consistent follow-ups. For older adults with low energy and memory problems, using the monitoring technology became even more challenging.

Additionally, usability concerns were raised, including older adults finding the text of the scale too small and experiencing difficulties with the blood pressure cuff, particularly in size and operation. Tablets provided for home use also encountered problems, such as screen freezing and cord malfunctions, further complicating the monitoring process.

Older adults expressed dissatisfaction with the information and training provided during the installation, describing it as fast, insufficiently detailed, and with no opportunity to practice. This led to insecurity; instead, they needed the support of assistant nurses during home visits.

In fact, I thought it was really bad because you did not get to know that much.

Yea, not that good; they were too stressed.

They put it there and then just left. Later, I asked someone from the home care to explain to me how it was supposed to work.

For some older adults, not all sensors worked when installed and no replacements were provided during the intervention.

No, I pointed it out several times (that the sensors did not work), but like nothing happened, so I have never used it, not once.

Furthermore, only one older adult expressed receiving written manuals but found the manual difficult to understand.

Weighted Results and Clinical Implications

Table 4 presents the weighted results and clinical implications of the quantitative and qualitative data collection, divided into five weighed results and implication points.

Table 4 The Weighted Results and Clinical Implications from Quantitative and Qualitative Data

Discussion

The project, initiated in 2020, faced challenges in implementing new workflows, especially when integrating technology. However, known concerns and limitations of using TM in clinical practice include usability, acceptability, and its appropriateness for real-world disease management, and integration into clinical and technical workflows.²²

Overall, the quantitative results revealed discrepancies between older adults and HCPs regarding security, concerns, technical difficulties, and the necessity of TM, similar to the findings of a previous study.²³ These discrepancies stem from inadequate person-centered care. HCPs consider care to be person-centered; however, a gap exists between the conceptual understanding of person-centered care and its practical application [23]. For care to be person-centered, HCPs must recognize individuals as unique, build meaningful partnerships, and create opportunities for patients to be actively involved in and empowered to take control of their care.²⁴

This study utilized two main data sources––HCPs and older adults. Overall, while both groups acknowledged the potential benefits of TM, they identified clear areas for improvement, particularly regarding technical reliability, education, and person-centeredness. HCPs focused on the operational challenges and benefits, and older adults highlighted their personal experiences and technology usability. Addressing these concerns can enhance the effectiveness of TM systems and ensure better outcomes for older adults. Similar concerns about person-centered care have been previously investigated in patients with heart failure,²⁵ highlighting the importance of addressing clinical and patient barriers to achieving person-centered care.

Additionally, a deeper understanding of how technology interventions and incentives motivate health behavior change is needed. For example, previous studies have discovered that most devices result in only short-term changes in behavior and motivation.²⁶ Gaining a better understanding of how individuals’ interface with health-related technologies will assist in developing evidence-based devices capable of fostering long-term behavior change. This deeper understanding of the relationship between technology and illness fosters a greater sense of responsibility for disease self-management, contributing to empowerment and enhancing motivation and adherence to health technologies.^26,27 By incorporating these insights, healthcare providers can better support personalized and meaningful behavior change. However, this was an important aspect that our study did not fully achieve, highlighting a key area where our results fell short.

Evidence supporting remote patient monitoring is growing, particularly for patient safety, adherence, mobility, and functional status.²⁸ Hospital at home and TM have also been supported as cost-effective solutions in the literature.^28–30 Integrating human elements with technology is of significant interest.²⁸ Remote patient monitoring technology is effective; however, integrating it with strong human interaction could enhance overall effectiveness and improve patient experiences and outcomes. However, our study revealed that key aspects of TM, such as follow-ups, training, and education, were insufficient. HCPs indicated a need for more in-person visits, while the person-centered approach was often overlooked. Additionally, older adults and their relatives expressed concerns about the reduced human contact, resulting in increased feelings of loneliness.

Recruiting older adults was challenging because of the sedentary and frail nature of the participants, who were living with chronic conditions and required specialized healthcare and social services. Additionally, technical issues and delays posed significant challenges for older adults and HCPs, leading to frustration and impatience on both sides.

HCPs highlighted the need for better information dissemination and more comprehensive training to ensure that patients understand how to use the sensors correctly, a concern echoed by older adults and their relatives. Furthermore, improving the usability of the equipment, such as enlarging text and ensuring that the blood pressure cuff fits properly, would enhance the user experience. Measurements of functional saturation were also identified as valuable indicators.

Ensuring that technology can be used independently by older adults without requiring constant support from healthcare personnel is crucial for the success of home monitoring solutions. In this study, the TM solution and accompanying services did not adequately meet the needs of older adults, HCPs, and the research objectives, contributing to many of the challenges reported in this study. The company providing the service lacked sufficient expertise, and the technology was untested and there was not sufficient support which resulted in numerous problems. Technology can increase accessibility, equity, and cost-effectiveness––key considerations when healthcare resources are limited––however, this study underscored the importance of adapting the technology to meet the specific needs of end-users. Additionally, the provider must be dedicated to offering sufficient support during the entire process.

Several limitations of this study should be acknowledged. The sample size was relatively small, which may limit the generalizability of the findings. Therefore, the results should be interpreted with caution and considered within the context of this limitation.

However, this study also has important strengths. The focus on older adults with chronic conditions, combined with care delivered using technology, addresses a population and context of increasing relevance. The challenges highlighted in this study provide valuable insights that can inform the design and planning of future research in similar settings.

Conclusion

Based on the experiences and perceptions of older adults and HCPs, the proactive approach used in this study effectively raised health awareness among older adults. However, it proved resource-intensive, raising concerns about the sustainability of such interventions within healthcare systems. The results emphasize the importance of person-centered care but indicate that these aspects were not fully realized in our study. This highlights the need for further research and refinement in TM implementation to better meet the needs of older adults, their families, and HCPs.

Additionally, this study underscored the importance of understanding how technological interventions can motivate short- and long-term health behavioral changes. Effective follow-up, training, and education are essential for successful TM interventions and their implementation in healthcare.