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Chronic Disease Management

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Patients with multiple chronic conditions have complicated care needs. We help your remote patients adhere to complex care programs through telehealth, care coordination, remote patient monitoring, and education.

Care Outcomes

Better care outcomes

Educating patients, engaging them in their own care, and taking timely actions all contribute to better health outcomes.

Reduced readmission

Patients with multiple chronic conditions are often readmitted to hospital as a result of unexpected changes to their health. Engaging and monitoring these patients helps to detect problems early and avoid unnecessary readmission.

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Costs

Reduced costs

Travelling to conduct patient visits costs time and money. Replacing in-person visits with online assessments increases efficiency and minimizes expenses.

What our customers say about us

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The Aetonix system allows for care conferencing; to be able to connect with other care professionals, to establish patient centred goals, to look at the care team, to determine together how we can best achieve health and wellness for the patient.

Laurie Hebert, Registered Nurse

Care Coordinator, AROW Health Link

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Schedule a discovery call

Wondering if we are a right fit, or have any particular questions that you want answered? Let’s discuss.

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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).