Providing Care Virtually Throughout COVID-19 with Care Pathways

It comes as no surprise that COVID-19 has completely altered the way healthcare organizations operate. Many have fostered digital solutions to avoid unnecessary in-person meetings and others have begun working from home all together to help stop the spread of the virus. 

Of course, when dealing with patients who have ongoing health issues or require physical examinations, this can make day-to-day processes a bit more complicated. Carefor, the largest not-for-profit charitable home and community services organization in Eastern Ontario, is one of these leaders who have adopted new practices in order to continue assisting patients throughout the pandemic. 

How Local Healthcare Organizations Have Adapted

Carefor supports thousands of patients in the Outaouais region, from Renfrew County to the Eastern Counties together with parts of Gatineau. Their staff work to provide care to patients, mostly elderly, throughout their various hospices, residential care homes, and palliative care programs. As elderly patients are among those who are most vulnerable to complications from COVID-19, the staff have had to adapt digitally in order to limit contact, while still delivering quality care.

Incorporating a Digital Solution

This is where the organization has taken advantage of Aetonix’s remote care coordination platform, aTouchAway. This platform enables all members of the patients care team – RNs, therapists, families, etc. – to connect and share information in one place, virtually. Introducing aTouchAway to their patients and staff has allowed Carefor to create virtual COVID-19 screening pathways, support secure video conferencing and messaging, and enable the care team to see multiple patients at once regardless of their location. 

This innovative platform has been used to not only monitor the health of Carefor’s patients throughout the pandemic, but also their staff. Deploying this app amongst this organization has allowed them to slow the spread of the virus and protect those who are most vulnerable.

To learn more about how Carefor has successfully used aTouchAway™ by Aetonix to move their care virtually, read the case study here.

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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.

  • 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
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).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB breathing 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).
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.

  • 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.