Aetonix Presents: The Care Pathway

What is the Aetonix Care Pathway?

At Aetonix, we recognize that the patient journey is a challenge for people at all levels of the healthcare system. This is true in all care settings, and also when patients are transitioned between care settings. Clinicians become disconnected from patients, patients feel lost, and families are left wondering how they can help. The Aetonix care pathway is a solution designed to address the challenges and keep each patient’s journey on track.

The Care Pathway

The Aetonix care pathway is an all-inclusive customizable package consisting of clinical workflows, assessment forms, and educational materials. It allows healthcare organizations to guide and coach care team members, caregivers, and patients on the right actions to take during the entire care process.

This tool keeps all parties aware and connected throughout the patient journey. In this age of patient-centric care, you can set a personalized path for your patient and care team to follow that helps comply with guidelines, standardize care, and optimize patient health outcomes.

It also improves the care experience for healthcare professionals by making them more efficient. Furthermore, it provides easy access for adding any other stakeholders to the patient’s circle of care. Thus, it’s a win-win for all!

The Aetonix care pathway has six defining characteristics.

1. Condition- or Procedure-Specific

The Aetonix care pathway provides multiple pathways depending on the condition of the patient. These include options for:

  • Patients with one or more chronic conditions such as diabetes, chronic obstructive pulmonary disease, or heart failure
  • Patients with a more acute condition that requires a home intervention such as mechanical ventilation
  • Various procedures, including elective surgeries such as cancer removal and same-day surgeries like joint and hip replacement

2. Involves Everyone in the Patient’s Circle of Care

Aetonix recognizes the multidisciplinary nature of the modern healthcare workforce. In the course of the care journey, patients come into contact with physicians, specialists, nurses, therapists, pharmacists, caregivers, and many more people who play a part in treating and managing the patient.

With all these parties involved, it’s helpful to have a standardized a clinical protocol for all members of the care team to interact with the patient. With the Aetonix care pathway, everyone knows their role, and their boundaries. The care admin can grant different levels of privileges depending on the role of each member.

3. Acts as a Coaching Tool

The care pathway is not merely a series of protocols that outlines the clinical roadmap for each patient. It is also a coaching tool that guides every participant on the best action to take at that point of time.

Simply upload educational material surrounding the case into your library in order to educate the patient, caregivers, and care team members. This material provides team members with continuous guidance on what they must do at each step, and how best to do it.

By educating and coaching the patients, you can help them live healthier lives via self-care or recover faster from a procedure.

4. Provides a Live Care Experience

The care pathway is much more than a digitized care plan. It not only outlines the course of treatment, but accounts for the different outcomes that may occur.

The care pathway is a live-action plan that details the steps to be followed in the course of treatment. Depending on the symptoms of the patient, each step can have multiple routes of action. The pathway provides live guidance to the care team and patient on the care to be provided, and this guidance can be adjusted based on clinicians’ decisions or the patient’s real-time data.

5. Serves as an Information Tracking Tool

In an industry as sensitive to information as healthcare, accurate documentation is essential. The Aetonix care pathway helps to capture patient information through remote monitoring of vital signs, customizable assessment forms, health questions, and symptom surveys.

Through the care pathway, healthcare professionals can track or acquire health data which helps in making better informed clinical decisions and evaluating the patient over time. All patient information—like medication history, hospital visits, conditions, and plans of action—can be included in the forms.

6. Flexible and Customizable

We have off-the-shelf pathways that are ready to be implemented, borrowed from other organizations. You can use these as is, or adapt them to create your own care pathways.

We understand that every organization is different, down to the departmental level. You’ve developed your own evidence-based clinical workflows, educational materials, and assessment forms to use with your patients and their care team.

Our Professional Service team has the experience and talent to help you apply your own protocols to create pathways that take your patient care delivery to the next level.

Aetonix Care Pathway

Looking Ahead

For managing chronic or weakened patients at home, facilitating their transitions from one setting to another, and helping isolated patients connect to both clinicians and the outside world, the care pathway is a one-stop solution. Whatever situation your patient is going through, Aetonix can help smooth the journey with the care pathway, using the aTouchAway™ platform.

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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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