Multi-Condition (COPD, CHF, Diabetes) Disease Management
Pathway Objectives
To monitor patients with multiple comorbidities including heart failure (HF), COPD, and diabetes (DM) so they can feel safe and supported at home.
Timeline: Daily. Ongoing
Circle of Care – Patient & Care Team
Nurse, Physician, Diabetes Educator
Initial assessment including labs, comorbidities, patient history including smoking, sleep apnea, presence of pacemaker (atrial fibrillation [AF] or cardioverter-defibrillator systems [ICD])
Daily monitoring including vital signs, O2 for all conditions. For HF weight monitoring is added, for Diabetes glucose monitoring is added
Smoking cessation program (if patient is a smoker) is offered and care team is notified of patient’s request for enrollment
Questionnaires related to breathing, weight gain, edema, and overall condition (symptoms) are provided to the patient; based on patient response
and associated condition, educational material, and medication management are reinforced
Care team is notified of values that are out of range; clinical interventions include symptom management techniques for shortness of breath (COPD), hyper or hypo glycemia protocols (DM), and patient notification to contact their care team for any urgent issues (patient can contact care team directly from platform)
A virtual visit is arranged by the care team to address any urgent reactions
Patients are instructed to go to ER for symptoms (individualized) identified as abnormal that require immediate attention
Care Pathways
Improving the wellbeing of your patients is our number one priority. That is why we offer a wide range of care pathways, to meet individualized health needs.
What our customers say about us
Using the aTouchAway™ COPD Care Pathway, we have been able to support our patients at home with required respiratory and oxygen therapy, managing them safely and avoiding unnecessary hospital or clinic visits. aTouchAway™ proves to be effective in augmenting patient care while expanding team capacity and saving travel time for our organization.
Miriam Turnbull
VP & GM at ProResp
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