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Multi-Condition (COPD, CHF, Diabetes) Disease Management

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Pathway Objectives

To monitor patients with multiple comorbidities including heart failure (HF), COPD, and diabetes (DM) so they can feel safe and supported at home.

Timeline: Daily. Ongoing

Circle of Care – Patient & Care Team

Nurse, Physician, Diabetes Educator

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Initial assessment including labs, comorbidities, patient history including smoking, sleep apnea, presence of pacemaker (atrial fibrillation [AF] or cardioverter-defibrillator systems [ICD])

Daily monitoring including vital signs, O2 for all conditions. For HF weight monitoring is added, for Diabetes glucose monitoring is added

Smoking cessation program (if patient is a smoker) is offered and care team is notified of patient’s request for enrollment

Questionnaires related to breathing, weight gain, edema, and overall condition (symptoms) are provided to the patient; based on patient response
and associated condition, educational material, and medication management are reinforced

Care team is notified of values that are out of range; clinical interventions include symptom management techniques for shortness of breath (COPD), hyper or hypo glycemia protocols (DM), and patient notification to contact their care team for any urgent issues (patient can contact care team directly from platform)

A virtual visit is arranged by the care team to address any urgent reactions

Patients are instructed to go to ER for symptoms (individualized) identified as abnormal that require immediate attention

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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


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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