COPD Post Discharge and Rehabilitation

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Pathway Objectives

To provide support and rehabilitation to COPD patients at home to prevent exacerbation

Timeline: In hospital prior to discharge, then for 10 weeks at home post discharge

Circle of Care – Patient & Care Team

Nurse Practitioner, Physiotherapist (PT), Care Coordinator

Assessment questionnaires are provided to the patient prior to discharge by the care team. Target O2 stats and exercise schedule is determined collaboratively between the patient and PT

Self-management questionnaires are provided prior to patient discharge, pre and post exercises to monitor symptoms (vitals and O2 stats taken an hour prior to exercise)

Virtual PT visits are scheduled weekly

Weekly education including learning modules, and biweekly (2x /week) exercise programs

Reminders are set for patients an hour prior to scheduled exercises. Exercises are performed within a virtual group setting and patients are assigned a buddy to enhance engagement and accountability (patients also have the option to do exercises on their own)

Education is provided asynchronously using videos (scheduled) and synchronously done live with their assigned buddy (scheduled)

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.

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What our customers say about us

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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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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).