How Virtual Care Pathways Are Improving Care for Patients Living with Chronic Illnesses

For patients living with a chronic illness, fluctuations in symptoms are common. With these changes in health comes the need for care adjustments, whether it be new or increased medication, therapies, or any other measures their care team determines necessary. To effectively meet the needs of these patients, many healthcare providers are turning towards virtual care pathways to efficiently track patients’ symptoms and help them regularly manage their illnesses.

 

Woman with chronic illness talking to doctor

Chronic Illnesses That Can be Managed With Virtual Care Pathways

Chronic illnesses are persistent health conditions that require continuous attention and treatment. To be classified as “chronic”, a condition typically must last longer than three months, however, many chronic illnesses require life-long care. Some chronic illnesses that commonly affect patients and require continuous care include: chronic obstructive pulmonary disease, asthma, diabetes, hypertension, arthritis, among others.

As many of these illnesses are quite common, medical experts have had the opportunity to assess frequent symptoms based on a great deal of patient data. This has allowed healthcare providers to gain access to a number of useful resources, such as virtual care pathways, that can aid in efficiently identifying and treating symptoms of these common illnesses.

Benefits of Adopting Virtual Care Pathways

Telehealth tools such as virtual care pathways can significantly improve the way healthcare providers deliver care to their patients. With the convenience these pathways offer, and the positive implications of detecting and managing symptoms early on, it is clear to see why this virtual care solution is becoming a regular part of care for those living with chronic illnesses.

Improves Efficiency Among Staff

Group of hospital staff discussing patient

With traditional care pathways, when a patient notices changes in their symptoms, they are to notify their healthcare provider right away. Healthcare providers can then assess the situation, and make adjustments to their patients’ care plans accordingly. While this process is effective in managing patients with chronic illnesses, it can often be complex, and requires time and resources in order to manually make adjustments to care plans.

One way healthcare providers are improving this process is by utilizing virtual care pathways. Virtual care pathways allow providers to review patient symptoms as soon as they occur, and follow a pre-established set of steps to begin improving their condition promptly. This can all be done through telehealth platforms such as aTouchAway, drastically reducing the amount of time care providers must spend assessing each patient, and also reducing the clerical work that goes into documenting and recording patient notes.

Meets an Increasing Demand From Patients

Female doctor virtually consulting patient

For those who live with a chronic illness, frequent in-person healthcare appointments are often a regular part of life. While in-person appointments are important in certain circumstances, there are many instances where these appointments can be replaced with more convenient methods of care. For this reason and others, patients are increasingly opting for telemedicine solutions for managing their illnesses.

With the COVID-19 pandemic introducing many new patients to solutions such as virtual care pathways, the demand for remote care is expected to continue increasing. In fact, 83% of patients expect to utilize telemedicine even after the pandemic comes to an end and we return to normal. By providing patients who have a chronic illness with access to virtual care pathways, you can ensure your healthcare practice is able to meet this demand while maintaining a high standard of care.

Provides Better Visibility of Patient Requirements

Virtual care pathways can differ in how they function depending on the telehealth platform you use, and the specific illness being managed. Many virtual care pathways, however, allow patients to input their symptoms on a regular basis, which provides their care team with regular health updates.

This type of monitoring has been shown to reduce hospitalizations and prevent disease complications. The input of real-time symptoms enables healthcare providers to get notifications when troublesome symptoms arise, and take action to help their patients as soon as possible. Patients can also receive automated messages when specific symptoms arise that highlight the steps they should take to begin managing them. When swift action is taken to alleviate exacerbating symptoms, patient outcomes ultimately improve, and chronic illnesses can become easier to live with.

Drawbacks of Virtual Care

Patient on virtual call with doctor

While there are many benefits to utilizing virtual care pathways for patients with chronic illnesses, there are some elements of virtual care that can present challenges for some. Some of the most common drawbacks include: patient technology barriers, difficulty implementing virtual care systems within healthcare organizations, and educating staff and patients on the various elements of these systems.

Although it’s crucial that these challenges are addressed, it is important to note that there will be hurdles when implementing any new healthcare process, and with the right tools and information, overcoming these drawbacks is possible. Healthcare organizations can improve the implementation of virtual care pathways by ensuring they use a platform that can easily be accessed by patients, and has a user-friendly interface that allows staff and patients to seamlessly operate its features.

Continuing To Improve Outcomes for Patients With Chronic illnesses

Continuous care is essential to improve the health outcomes of those living with chronic illnesses. When managed and cared for properly, many chronic conditions can become easier to live with over time, and patients can see major improvements in their overall quality of life. With healthcare tools such as virtual care pathways, healthcare providers can continue to support patients by regularly screening the status of their health and providing updated treatment recommendations and plans.

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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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