Care Pathways

A care pathway is a package that includes assessment materials, a roadmap that describes the flow of actions that the care team, patients, and other members of the circle of care will be guided by, and the education material required to help patients understand their condition and treatment plan.

 

Below is a summary of the features offered in each Care Pathway. For more information about a Care Pathway, scroll to the Care Pathways directory ↓

Live Care pathways

Vitals

Alerts

Questions

Education

Equip. Mgt. / Medication

Wound Mgt.

COPD Rehabilitation



COPD Post Discharge Stabilization + Monitoring Service



Multi-condition Disease Management



Pediatric Mechanical Ventilation



Diabetes and COPD Management



Palliative Management




COPD & HF Management



Live Care pathways

Vitals

Alerts

Questions

Education

Equip. Mgt. / Medication

Wound Mgt.

Post Op Cardiac Surgery



Pre/Post Orthopedic Hip/Knee Surgery



Pre/Post Caesarean Surgery


COVID Patient Positive Monitoring


Pre/Post Cancer Surgery

COVID Staff Management


Clinician reviewing imagery of lungs for COPD as part of check-up after concerning assessments

Chronic obstructive pulmonary disease (COPD) care pathway

The COPD care pathway runs a daily patient assessment and will guide on actions to take to avoid readmission to hospital. Patient status will be color coded and notifications delivered to the care team on criticality of the intervention required. The patient will be presented with educational material based on symptoms identified in order to help address the issues and avoid a visit to the clinic. The pathway includes educational material on inhalers, breathing positions, and others.

Diabetes care pathway

The diabetes care pathway runs a multiple daily assessment of glucose level check. The workflow invites the patient to enter its glucose level and based on the value will provide direction to the patient on the next steps and will alert the care team. Patient color status is available. Actions to patients can be to reduce insulin level, review care plan, and read about resources. Actions can also be to remind about insulin, increase insulin, have a snack, or others. In the context where the care coordinator or diabetes educator is notified, a virtual call may be scheduled for a follow-up.

Man testing his glucose levels to input into aTouchAway for care advice, such as reducing insulin levels
Elderly woman with multiple diseases receiving daily assessments for COPD and Diabetes

Multiple condition care pathway

In the context where patients have multiple diseases this pathway includes a workflow that will assess daily a patient for Heart Failure, COPD, and Diabetes. The workflow can be personalised for patient base conditions across multiple diseases or customized to their specificas around heart failure, COPD or diabetes. The pathway includes educational material to help with diet, breathing condition, exercise, and others. Patient color status available and notification to the care team available.

COVID 19 Staff screening care pathway

For COVID 19, Aetonix developed a workflow to help assess on a daily basis if the staff of a home care agency or hospital can return to work through a set of questions and temperature measurement. The tool helps with staff management and coordination. The workflow will assist the triage team to set meetings with the employee, complete consultation, and decide on a safe return to work date.

Hospital staff with visor and mask testing for COVID-19 to manage and coordinate its pathway
Man on mechanical ventilation system at home who receives remote support by their care team

Mechanical ventilation care pathway

The pathway supports patients using ventilation equipment at home to receive remote patient support by their care team. The pathway includes educational material to guide the patient or caregiver to understand better how to use ventilation equipment. The pathway includes a workflow that will guide the patient on assessment to complete but also on how to use the ventilation equipment. When plan deviations occur, the patient will be color coded as status and notification will be provided to the care team for intervention.

Changing lives daily.

Five star rating

With aTouchAway COPD Care Pathway, I have been able to monitor, guide, and take actions when required for my patient in the community. It has provided me with an additional tool to support a very complex patient population

Donna Cousineau

Advanced Practice Nurse, Chronic Disease Management, Queensway Carleton Hospital

Get in Touch

All our care pathways can be fully customized to meet the clinical or care team needs.

Please contact us if you’d like to discuss.

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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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