Office of the Chief Health Innovation Strategist enables better care for patients – right at home in eastern Ontario

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Office of the Chief Health Innovation Strategist enables better care for patients – right at home in eastern Ontario

A select group of complex-care patients in eastern Ontario will be cared for using new technology right in their own homes.  On November 30, 2017, William Charnetski, the Chief Health Innovation Strategist for Ontario (OCHIS), is kicking off the deployment of aTouchAway by Aetonix Systems, in the Arnprior Region & West Ottawa (AROW) and Upper Canada (UC) Health Links.

This project is one of 15 that received funding in the first round of Ontario’s $20-million Health Technologies Fund (HTF).  Administered on behalf of OCHIS by Ontario Centres of Excellence, the HTF is part of the OCHIS mandate to strengthen Ontario’s health innovation ecosystem.

“The Health Technologies Fund is already having an impact in the health system because of the collaborations it has created between health service providers, health technology innovators and patients,” says William Charnetski, Ontario’s Chief Health Innovation Strategist. “We are finding new ways to solve our greatest challenges by harnessing the power of innovation to provide better care while creating jobs in Ontario.”

The AROW and UC Health Links are partnering with both private and public organizations to deploy the innovative telehealth technology developed by Aetonix.  aTouchAway is a communication platform designed for seniors and others with complex healthcare needs. It connects all of their healthcare providers and caregivers, including family members, on one secure, easy-to-use digital platform. Members of a patient’s circle of care can see, speak with, assess and support the patient directly through a tablet or smartphone application. aTouchAway provides one-touch secure video conferencing and treatment / care plan information-sharing.

In Ontario, five per cent of patients account for two-thirds of all healthcare costs.1 These are most often patients with multiple, complex conditions. There are 90 Health Links across Ontario that are providing a new service delivery model focused on coordinated care planning. Care coordinators work with each patient to develop individualized care plans. When the hospital, family doctors, community organizations, informal caregivers and others work as a team, patients receive better, more coordinated care.

“Health Links have allowed me to create, and enjoy, a new life,” notes one AROW Health Link client. “Everyone has been fantastic and I now have someone who looks after me where it’s most comfortable – my home. My care coordinator is my ambassador.”

The AROW and Upper Canada Health Links connect patients with more than 50 agencies, including hospitals, primary care teams and community service agencies.  “Enhanced connectivity will significantly improve the flexibility and capacity of our Care Coordinators. They can work with the care team to address each patient’s unique healthcare goals,” says Cholly Boland, CEO, Winchester District Memorial Hospital, which is the lead partner for the Upper Canada Health Link.

“Minister Hoskins is committed to integrated, accessible care closer to home and this is a great example of what is possible. Health Links focus on the most complex and vulnerable patients and this type of coordinated care will support them right in their own homes,” adds Eric Hanna, President & CEO of Arnprior Regional Health, which is a lead partner for the AROW Health Link.

The program is further enabled through financial and in-kind contributions by partners, including: Samsung Canada, Boehringer Ingelheim (Canada) Ltd., and the Canadian Foundation for Healthcare Improvement (CFHI).  The Women’s College Hospital Institute for Health System Solutions and Virtual Care (WIHV) is also leading the evaluation to see how effective the tool is at improving access to care for patients with complex needs.  Total funding for the program is $1.2 million.

“Aetonix is so proud to be working with these health and technology partners to innovate in home healthcare and help Ontarians receive better care at home,” explains Michel Paquet, CEO and Founder at Aetonix.  “We are offering Ontario’s Health Links a truly unique solution that will improve patient outcomes and experiences, while enabling efficiency.”  Based in Ottawa, Aetonix is an Ontario-born virtual home care technology company whose mission is to revolutionize how families, healthcare professionals and caregivers connect a patient’s circle of care.

PARTNER VOICES

“We’re pleased to be among the group of partners selected to implement the Aetonix aTouchAway solution, an innovative model that will empower health care providers to bring coordinated care into the homes of patients. As an organization committed to the development of solutions that will improve healthcare delivery for patients, we are excited to witness the positive impact this model will have on Ontarians living with chronic and complex conditions.”  – Richard Mole, President and CEO, Boehringer Ingelheim (Canada) Ltd.

www.boehringer-ingelheim.ca

 “Samsung is proud to partner with Aetonix on this milestone achievement in healthcare technology. Together with the Aetonix aTouchAway application, our innovative mobile solutions are keeping healthcare practitioners and patients more connected and impacting patient care across Canada.” –  Paul Brannen, Executive Vice President, Mobile Solutions at Samsung Canada

www.samsung.com/ca/

 “WIHV is committed to finding new ways of keeping seniors and all patients with complex care needs closer to home. We’re excited to evaluate the aTouchAway solution to look at the potential it has to help patients and the healthcare system overcome some of the biggest barriers to care and create better outcomes for everyone.” – Dr. Sacha Bhatia, WIHV Foundation Director, The WCH Institute for Health System Solutions and Virtual Care

www.wchwihv.ca

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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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