Using a Mobile App for Remote Chronic Care: an RN’s Perspective

If you provide care to patients dealing with chronic conditions, you know it is not an easy job. Fortunately, with advances in technology, this doesn’t always have to be the case. More healthcare professionals and facilities than ever are using digital technology in their practices. And for good reason – a study from Ricoh Research shows that 74% of hospitals that use mobile solutions to collect and share data are more efficient than those who don’t.

Aetonix’s mobile app, aTouchAway, has been deployed in various healthcare organizations for this purpose. The app connects the entire circle of care on one platform, allowing for seamlessly sharing updates on the patients’ health in real-time. This ensures that everyone is up-to-date and actively involved in the patient’s care. The patient also has the ability to self-manage their own care. aTouchAway’s integration with home health equipment allows for the patient to monitor their own condition. For example, a physician could set up a customized protocol (workflow) that asks their patient with diabetes how they are feeling on a scale of one to ten. If their response is lower than five, the physician can instruct them to use a pulse oximeter to measure their blood oxygen levels. When set up with the proper equipment, the patient will be able to do this themselves from the comfort of their home.

Thamesview Family Health Team

The Thamesview Family Health Team is an organization based in Chatham, Ontario, who use aTouchAway with their patients. They are a family health team made up of 16 family physicians and more than 23,000 rostered patients. Other roles in the team include nurse practitioners, registered practical nurses, administrative and reception staff, social workers, and more. We sat down to speak with Laura Schauer, one of their registered nurses, about the work she does for her chronic patients using digital technology.

As a registered nurse at the Thamesview Family Health Team, she has a lot of daily tasks. “I do many regular ‘hands on’ nurse work such as injections, dressings, and blood pressures,” she says. “I also draw blood work, perform foot care, monitor our INR clinic, health and wellness checks, and am a smoking cessation counsellor and Health Links care manager.” Her role is essentially managing, supporting, and caring for their complex patients. These include people with multiple health issues, who are often elderly, isolated, or tend to end up in the hospital or emergency department more frequently than others.

Ontario Health Initiatives

Reports show that seniors with three or more chronic diseases use three times the amount of healthcare resources than those with none. “I do feel that with the number of rising seniors in our population, the number of people with ever-growing list of chronic health problems will also grow,” Laura says. As chronic diseases are on the rise, healthcare organizations must do what they can to keep these patients out of the hospital. Hospital readmissions are both costly to the system and stressful for the patients.

This family health team is part of the Health Links. Health Links is an Ontario initiative to provide better, more coordinated care to those with complex conditions. Organizations caring for patients involved in the Health Links must work to ensure that patients have a coordinated care plan (CCP) and ongoing care. The Thamesview Family Health Team is part of the Chatham-Kent Health Link. According to Laura, “In the beginning, our four RNs here actually were all involved [with Health Link patients] and we all had a designated ‘patient list’. As the Health Link role has expanded, we have found it much easier to have one main RN dedicated to the program and the rest help support the role.”

Of course, taking on the role of managing many complex care patients can come with its complications and challenges. Laura states that her biggest challenge is time. She and other nurses also have to factor in driving time for home visits and there are only so many hours in a week. They are challenged with trying to see as many patients they can with the amount of time they have.

Observing & Intervening

Fortunately, she does not always have to drive to see the patient in person. Using aTouchAway allows Laura to monitor her patients remotely. “Currently, I have a few different uses with my patients for aTouchAway,” she says. “Most notably is a patient with congestive heart failure (CHF) – they have their own blood pressure monitor and weight scale. They get their numbers for me every morning and enter them where I can then access them.” She is able to watch for trends and when she sees a sudden change, she can step in. Looking at the data, she noticed one of her patients began having low blood pressures. When she called the patient to discuss this and check in on them, they complained that they had been feeling dizzy. “I had to discuss with the patient’s physician and they ended up needing a lower dose of their blood pressure medication.” After the physician was able to remotely adjust the patient’s prescription, the patient reported feeling back to normal two weeks later. No in-person visits were required. In situations like this, it helps that multiple members of a patient’s care team can connect on the same platform.

“For someone flaring with their CHF,” she adds, “their weight may begin to climb, as might their blood pressure, and perhaps also their oxygen levels may drop as well. Having a nurse reviewing the trends of these numbers regularly gives us an idea as to what is going on, and a chance for early intervention.”

Improved Communication = Improved Outcomes

Another advantage she gets from using a mobile app for healthcare monitoring is the ability to send and receive photos. “We are also in the works of using aTouchAway for photo exchange,” she explains. “I have a patient that frequently gets cellulitis and they live far away. To have the ability for them to send a photo of the wound/potentially infected area and be able to get in touch with their physician quickly can mean an avoided hospitalization because we had a quick intervention.”

When asked about her personal experiences with the technology, she states “luckily the training to use the technology was pretty easy, which is helpful when trying to explain how to use it to others. Of our patients that currently have it, they have caught on pretty quick and are able to communicate with me, answer their reminder questions, and even upload their daily weight and blood pressures.” Of course, there are some patients who will still prefer the face-to-face visits instead. When finding the solution that fits best for your patients, ease of use is essential. Laura explains that some patients who have cognitive deficits or dementia, for example, may not remember how to use the system or operate a tablet.

Recent advances in technology may be the key to simplifying complex care. Laura Schauer has taken advantage of what mobile solutions can offer. “For patients with complex, chronic health conditions such as COPD or CHF, mobile health monitoring with vitals (blood pressure, heart-rate, oxygen, weight, etc.) is very helpful as changes to these numbers are sometimes the earliest indicators that something is amiss or an exacerbation is looming.” The ability to check-in on her patients without actually being there allows her to provide the same quality of care but in much less time. Not only does a mobile app save time for everyone involved, it allows patients to self-manage and still live independently. They are able to monitor their condition from the comfort of their home. Although chronic diseases are on the rise, with so many new technologies and programs available, there is reason to believe they can be managed easier than ever.

Featured image courtesy of eMedCert.

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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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