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Care Transitions

Enhancing Communication in Critical Care: The Virtual Way

Admission to the ICU for critical care is reserved for patients who have one or more impaired organs, or who require respiratory support. Directors of critical care and ICU directors in health systems are responsible for managing the patient experience in such settings.

When done right, communication in a critical care setting improves patient outcomes, boosts psychological recovery, and increases the satisfaction of both the family and the patient. These benefits have been clear in connecting ICU patients to their families during the COVID lockdown.

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  • Toutes les publications
  • Parcours de soins
  • Transitions de soins
  • Surveillance de patients à domicile
  • Rejoindre des patients isolés
  • Gestion des maladies chroniques

AETONIX FORME UN PARTENARIAT DYNAMIQUE AVEC RESPIPLUS™ POUR AMÉLIORER LA PRESTATION D’UN PROGRAMME D’AUTOGESTION DE LA MPOC DE RENOMMÉE MONDIALE

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AETONIX FORME UN PARTENARIAT DYNAMIQUE AVEC RESPIPLUS™ POUR AMÉLIORER LA PRESTATION D’UN PROGRAMME D’AUTOGESTION DE LA MPOC DE RENOMMÉE MONDIALE

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Études de cas

Dame aînée en chaise roulante utilisant une tablette pour lire au sujet des soins complexes virtuels.

RÉDUISANT L’ISOLEMENT SOCIAL ET MÉDICAL POUR LES ADULTES AYANT DES HANDICAPES

Médecin en combinaison de matières dangereuses aidant le patient infecté à parler avec sa famille alors qu'il est allongé dans un lit d'hôpital

OFFRANT LE CADEAU DE LA COMMUNICATION EN CAS DE BESOIN DE SOINS CRITIQUES

Rencontre virtuelle avec médecin sur ordinateur portatif pour discuter des prescriptions médicales.

AMENANT LA CLINIQUE AU DOMICILE DU PATIENT

Couple d'aînés main dans la main, se soutenant mutuellement pour leurs maladies chroniques.

INCITANT LA CONFIANCE CHEZ CEUX AYANT DE MULTIPLES MALADIES CHRONIQUES

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COPD Education – Onboarding

Objective
To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 
To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective
Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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