Chronic diseases are a global epidemic. Three out of five Canadians over the age of 20 have at least one chronic disease and many others are at risk of developing one. Caring for this group poses a heavy burden not only on caregivers, but also on the patient themselves. Many organizations who care for patients with chronic diseases have implemented technologies that make it easier for everyone involved. Mobile apps can be used for various purposes. The entire care team can connect in one place which fosters better communication and information sharing. Some platforms can be integrated with home health devices that the patient can use to monitor their conditions. They can share this information with their care team in real-time. The ability to monitor a patient’s condition remotely means that care providers can track their health and intervene when necessary. When an intervention takes place before the condition has the chance to get worse, it can avoid an emergency room visit or a trip to the doctors office. In this blog, we will be highlighting four posts explaining the various benefits an organization can have from using a mobile app for chronic disease management.
Integrations with home health monitoring devices
As mentioned previously, some apps allow for health monitoring through bluetooth devices. This post details the impact that encouraging your patients to use these devices for monitoring their chronic conditions can have. aTouchAway by Aetonix is a platform that supports real-time updates using various home health monitoring devices. These consist of a step counter, a fall detection/wandering bracelet, a pulse oximeter, a weight scale, a blood glucose meter, and a blood pressure monitor. They are easy to set up and use from the comfort of the patient’s home. When they patient has used any of these devices to monitor themselves, their results will be available to whoever has been permitted to view them. Care providers also find it especially helpful when the results can be represented in a graph or chart format. This makes it easy to spot any sudden changes in the pattern and make changes to routines/prescriptions if necessary.
Ability to observe trends and intervene
This post features an interview we conducted with one of our clients. Laura Schauer, a registered nurse with the Thamesview Family Health Team, sat down with us to share her experiences with using a mobile app for her patient’s chronic disease management. One story she told us particularly stood out. Laura explains that she has a patient with congestive heart failure who uses a weight scale and blood pressure monitor at home to share their results with her daily through aTouchAway. She noticed this patient suddenly had very low blood pressure readings. When she called the patient to discuss, they reported they had been feeling dizzy. Based off this information, Laura was able to discuss with the patient’s physician and agree on giving them a lower dose of their blood pressure medication. The physician was able to remotely adjust the patient’s prescription and the patient was feeling back to normal two weeks later. This is just one of many examples where healthcare practitioners are able to observe their patient’s health information through an app and take action.
Care Plan Sharing
Care plans are essential for patients with multiple chronic illnesses. They provide individualized guidance for the patient and their care team. This post details how digital accessibility to a patient’s care plan can improve the way their team provides care to them. When the whole team is kept up-to-date and informed of progress in one place, it is much easier to stay on track with the patient’s goals. Getting the patient set up on a mobile app along with the rest of their care team will help to ensure that the patient is kept at the centre of their care.
Reducing Hospital Readmissions
It’s no secret that hospital readmissions are part of what is so costly to our healthcare system. Especially when they are avoidable or unnecessary. This post looks at how using a mobile app helps to reduce these hospital visits. Patients who deal with a condition like COPD may be likely to go straight to the emergency room when they’re experiencing breathlessness. This is not always the right call, especially when there are other options available. Patients like these may take comfort in being set up on an app that connects them to their family and professional caregivers. If they are having trouble breathing, they are able to call someone close to them who can get a visual representation of how they’re doing and coach them on next steps.
If you or your organization are considering using a mobile app for your patient’s chronic disease management, we hope these posts will help give you further insight into the benefits it can offer you. Please feel free to look at our blog page for more articles on caregiving for patients with chronic conditions.
It happens far too often. A hospital will give a patient brief instructions upon discharge. The patient leaves saying they understand. When the patient follows up with their physician afterwards, they are unable to remember what exactly they were told. They tell the physician what information they think they can recall – which, of course, may not be as accurate as they think. This is just one simple example of what happens when health practitioners rely solely on the patient to deliver information from one end to the other. As you know, when a patient gives inaccurate information to their care provider, this can cause a lot of other difficulties and frustrations. It happens too often where information is not articulated properly or certain providers are not kept up to date. Patients may be given the wrong prescription doses or have to undergo unnecessary tests among many other inconveniences. When a patient’s care team are not connected and rely solely on the patient, this is where information gaps occur. In this blog post, we are going to look at three ways to close this gap and foster better communication within care teams.
1. Use a new technology
When an organization brings up the idea of introducing a new technology, the staff will naturally have questions. How do we know it’s secure? How easy will it be to implement? Will our patients be able to use it too? The key is finding the right technology that allows for all of this. These organizations take on more of archaic approach to communication at the moment, still using phones and fax machines. Although it may be effective, it can make the process of sharing information longer than it needs to be. For example, if a clinician needs to contact a physician for a consultation and the physician is not immediately available, they will likely have to go through other people whether it be a unit clerk or hospital call centre. By the time the message gets to the physician, it will have taken much longer than a direct text message would have. A recent study showed that 39% of physicians interview believe that time is being wasted because text messaging is not allowed. Although text messaging from their personal devices may not be permitted, there are some applications that allow for secure texting. The right mobile app will allow for much more than just texting too. A mobile app is the perfect platform to connect all members of a care team in real-time. It’s a platform where they can view the patient’s care plan and progress. The patient can even video conference with multiple members of their care team from the comfort of their home.
2. Establish clear contacts
In order for a care team comprised of members from various organizations to work in sync, they must know the most efficient ways to reach each other. All organizations operate differently with communication. The physician must know the best way to contact the patient’s pharmacist who, in turn, must also know how to contact the patient. This study shows that 1 in 5 Canadians with chronic conditions have experienced prescription errors or duplications. Should there be a change in a patient’s prescription, the physician cannot rely solely on the patient to pass this message along. The physician should establish a clear line of communication to the patient’s local pharmacist along with others in the care team.
3. Plan ahead
There are some situations, such as a sudden emergency room visit, that cannot be planned in advance. However, many other events can be. If the patient is about to undergo an operation, their physician should be informed if they are not already. In addition, a close loved one should not only be informed, but also know the proper pre/post operative care the patient may need help with. Many patients with multiple chronic conditions rely heavily on their informal caregivers to take care of them at home. The caregivers need to be given the information to properly do so. When everyone is kept in the loop about a patient’s care, it is much easier to avoid complications. Planning ahead can also consist of taking note of planned absences or vacations. Nothing will delay diagnoses and test results more than waiting on a practitioner who is on a two week vacation. Patients should not have to wait multiple weeks for important test results. In this case, it is helpful to prepare for any care team members absences and ensure that the patient will have a way of receiving their results. Working in the healthcare industry, you should inform your patients and their care team of any absences beforehand when possible.
It is clear that healthcare practitioners do not communicate enough with each other and even less with their patients. When a patient and their whole care team are kept up-to-date, it’s much easier to avoid complications. Whether these complications result from misunderstood instructions, inability to reach a care team member, or a lack of information, one thing is for sure: communication is key.
A Project Manager plays an essential role in the healthcare system. They are responsible for creating a detailed plan once a new program is established. This means that they are involved from start to finish and also have to prepare a quick solution should a problem arise. As you can imagine, it’s quite a busy and demanding role. Other tasks include reporting on progress and supervising other members involved in the project.
In this blog post, we would like to introduce you to Joshua Hambleton, a Project Manager with the Arnprior Region and Ottawa West (AROW) Health Link. The Health Links are an initiative established by the Ontario government to provide coordinated care to the top 5% of healthcare users across the province.
What makes this program unique?
Unlike other approaches, the patient is put at the centre of their own care. Their team of providers will establish a care plan and the patient and their family will work together with them to ensure the patient is receiving the care they need. Caring for this specific group of patients with complex needs is essential. If they are not getting the care they require or something goes wrong, they are likely to end up back in the emergency room. Hospital readmissions are especially costly on the system. By providing more accessible and frequent care, more patients are able to manage their conditions at home. Joshua has worked with patients like these during his time at the AROW Health Link for the past four years. He sat down with us to share more about managing complex patients and how using a mobile healthcare app has impacted this role.
When asked to begin by defining his goals as part of the organization, he responded, “we focus on client goals, the care teams, and connecting the care teams around the client’s priorities”. His role as an implementation manager is to make sure the organization is taking on a patient-centred approach – this includes anything from business planning to the actual implementation and evolution of the approach. “I first became interested in Health Links as I was exploring opportunities to work between agencies,” he explains. “I’ve worked in acute settings, primary care, community care, and I recognized that where I’m able to contribute the most is working in a space that there was a greater opportunity to apply my skills and experience.”
Closing the “Gap”
What interested him particularly about working in a Health Link is the opportunity to close, what he refers to, as the “gap”. “I became involved with a Health Link focused on working between agencies in the gap where often the relationships were referral based or dependent on the patient to carry that information from provider to provider,” Joshua says. As you can imagine, when healthcare providers rely solely on the patient to keep them up-to-date, there may be gaps in information.
Working in a network of different specialists and organizations is much different than working in a single agency. “One of the biggest challenges is getting people to think outside of their organizations and how we go broader,” he says. “Whether it might be mental health, an acute setting, or geriatrics, how do we link these networks together so that we’re sharing information and have better communication across providers?”
What makes this even more complicated is that each organization has their own proprietary health records. Joshua adds that communication between these organizations is usually still done through fax or phone – a more old-fashioned approach. “How do we share information and make it as real-time and relevant in that environment as possible?” he asks. They may have found the solution… and it comes in the form of a digital platform.
Introducing a New Technology
The AROW Health Link (and many other Health Links) have been using aTouchAway in an attempt to bridge the gap. aTouchAway by Aetonix is a remote communication platform designed to help manage the care of multiple patients with complex needs securely. According to Joshua, aTouchAway has been effective for enhancing better communication, “whether it’s sharing documents like discharge summaries or just general updates about home visits or the updated coordinated care plan”.
Connecting the Whole Circle of Care
Many times, healthcare information systems don’t include the patient (and their family) in their own care. This is both surprising and slightly concerning considering families provide the majority of care to chronically ill patients. In fact, there are more than 8 million informal caregivers in Canada alone. How do we solve this disconnection? “Aetonix allows for a way to have informal caregivers be part of the care team with access to the care plans and to the broader professionals,” he says. One reason why patients and their families may not be able to be actively involved in their care is a lack of communication tools. Many patients have mobility issues or live in rural areas which may prevent them from being able to frequently see their health team. Since Joshua’s Health Link is able to work together with Aetonix’s partners (Samsung, Boehringer Ingelheim, and Bell), they can provide patients in their homes with tablets and a cellular connection. This way, even patients who previously had no internet connection at home have the ability to reach out for care whenever it’s necessary. Simple tasks such as follow-ups, appointment confirmations, and education can now be done through the software without the patient having to leave home.
Enhancing User Experiences
Joshua also uses the application himself for various purposes. “I tend to go to the app for sharing different client information with care teams and with those care coordinators,” he says. Since most of his work is done on a program level (and not a direct care level), he is more focused on engaging the care teams with the software and getting them to communicate through it more often. “It’s a new technology,” he explains. “So both in terms of whether it’s a care coordinator, the care teams, the clients, we have different levels of engagement. Even having the tablet there is a comfort and a reassurance for clients. Despite having, say low usage on the app itself, it’s just a knowledge that they can be connected should there be a challenge that they come across or they need to reach out.” He says they also have clients who use aTouchAway much more frequently. This use is mainly for connecting with their care team; both formal and informal.
He recalls some really positive experiences patients at his Health Link have had with the app. “A great story that I heard recently was this woman who was able to be connected to her daughters who lived across Canada, one on the East Coast, one on the West, I think someone in Calgary as well,” he explains, “this woman was able to not only connect with her family and her daughters, but was able to see their apartments for the first time due to not being able to travel.” For patients with mobility issues or who live far from their families, it is small things like this that will make using the technology worthwhile for them.
A Bright Future for Digital
“I think we’re just beginning to learn about what the advantages are of using a technology like Aetonix,” Joshua responds when asked about the future of solutions like aTouchAway. “I mentioned a couple of the projects that are underway and people are really getting excited about having the opportunity to explore how to use the technology. In the same way that the Health Link is really working in the “gap” between agencies, Aetonix has the same opportunity to work in that gap where we don’t have communication tools to be able to work the way that we need to in the future.”
It’s no secret that health care in Ontario is becoming more patient-centred. The province’s action plan for health care, Patient’s First, was enacted in 2015. In the time since, a significant shift has occurred. Now more than ever before, people are at the centre of the care they receive.
What does that mean? For many, “patient-centred” sounds like yet another health care buzzword. But those who work tirelessly in the sector can recall hearing it in many situations.
Putting a patient at the forefront of her care means looking at each step in her health care journey—from her point of view. It means respecting her wishes and medical preferences. And if you’re a care coordinator, it also means helping her set her own health care goals. If she is dealing with a challenging illness, you both know the importance that continuous care and encouragement can have.
Patient goal setting is an essential part of a care coordinator’s job. But it isn’t always easy. At different times during the goal setting process, you have to take on various roles. Translator. Educator. Advisor.
Helping patients set realistic objectives that they’re actually motivated to achieve is difficult job. But it can also be very satisfying.
In this post, we’ll look at some of the challenges associated with patient goal setting—and how to overcome them.
Be An Active Listener
It goes without saying that listening is one of the keys to understanding—and to serving others well. It’s also an important part of care planning, a crucial piece of which is patient goal setting.
As a care coordinator, you’ve engaged in clear and productive communication throughout your career. But developing listening skills is a lifelong pursuit—especially in health care. Truly hearing a patient is about more than absorbing information. It’s about listening for the specific information that will help you create a dialog.
As much as possible, you want to align a patient’s goals with his wishes and preferences. The best way to do this isn’t always through a direct question and answer format. Sometimes you can learn more about what a person really wants through conversation.
Engaging in active listening helps you take in what the patient says—and what he doesn’t say. You’ll end up with with a more complete picture of his perspective and relevant experiences.
There are many methodologies that use active listening techniques. Some are used regularly in health care environments.
As just one example, the South East Local Health Integration Network (LHIN) suggests using Teach-Back. Teach-Back encourages the use of plain language and open-ended questions. During patient goal setting, this communication style can help care coordinators go beneath the surface to find out what’s really most important to patients.
Active listening is also about ensuring that patients understand. Practicing these skills—by, for example, having patients repeat what you’ve said in different words—can make challenging situations easier.
What happens when a patient is adamant about setting unrealistic health goals?
During a difficult conversation (in an already hectic day), it can be tempting to let the patient gloss over reality. Practitioners aren’t always aware that they’re doing it. Using methods like Teach-Back forces coordinators to notice discrepancies in understanding—and work towards achievable goals.
Improve Health Literacy
The Ontario College of Physicians and Surgeons estimates that low health literacy costs the health care system as much as $10 billion a year. Needless to say, there are also sizeable personal costs for patients who don’t fully understand their care.
During patient goal setting, care coordinators need to ensure they’re speaking the same language as those they’re helping. Without a patient’s full understanding, the chances that her wishes and preferences will be reflected in her care plan are slim to nil.
In health care, it’s inevitable. There are times when it seems like practitioners in different areas of specialization speak completely different languages. Unfortunately, the patient usually doesn’t speak any of them. As a care coordinator, part of your job is translation.
To a large extent, you’re also an educator. You can improve a patient’s health literacy by providing her with access to resources. Whether it’s a sheet of nutrition tips or a short video depicting a simple wound dressing technique, educational resources can improve understanding.
Fully understanding these processes and their outcomes allows patients to see a broader spectrum of goals. Suddenly, achieving feasible, short-term goals begin to make sense.
As much as possible, be available to answer questions—and ensure that other circle of care members are, too. Communication technology can help in this regard. Introducing intuitive and convenient digital communication systems can improve conversations between patients and their care teams.
By now, you’ve almost developed the sense that patients don’t always understand their care as fully as they think they do. Because patient-centredness is a relatively new concept, the onus is often on care coordinators to improve patient comprehension.
It’s wise to devote much of your effort to improving health literacy. Realistic goals that truly reflect patient wishes frequently follow.
Improve Patient Engagement
There’s no doubt in the minds of health care professionals. Patient engagement is critical. It has the power to improve health outcomes and quality of life. It increases the likelihood that care delivery will run smoothly. And when it comes to goal setting, engagement plays an important (and direct) role.
When a patient doesn’t understand the reasons for key care decisions, how can she be invested in their outcomes? When she doesn’t comprehend what’s happening well enough to track her progress, how can she be expected to set specific, realistic objectives?
Vague, big picture goals—such as “getting well”—are made in part because patients have trouble participating in the process. It’s up to care coordinators to ensure that patients are active participants in their care.
Of course, asking for involvement is no small request. It requires a patient’s energy—and in many cases, a major mental shift.
Past experiences with the health care system have led many to believe that they should be passive recipients of care. But Ontario’s system is shifting. Leaders have begun to recognize that a reactive, acute care approach to dealing with chronic disease isn’t always best.
The best way to engage a patient in her care is to help her understand how her actions can contribute to positive outcomes. If she knows she can make real strides toward her goals, she’s far more likely to want to participate in goal setting.
Celebrating progress is also key—it encourages patients to track their progress, take part in reevaluation, and adjust objectives accordingly.
When it comes to engaging at-home patients, communication apps can help. Intuitiveness is important, so look for features such as touch-screen accessibility.
Patient Goal Setting: Encouragement and Collaboration
As a care coordinator, you help patients set health goals that are both reasonable and satisfying. But during this process, there’s no shortage of potential challenges.
Luckily, focusing on communication can help. By ensuring patients understand all relevant health information and encouraging them to take an active role in their care, you can set them up for success.
Featured image courtesy of Medical Recruiting.