Rick’s Story

On July 27th, 2016, Rick O’Neil woke up in a bed at Arnprior Hospital. He had no idea what he was doing there.

When he noticed two red marks on his chest, the doctor had to explain that they’d been caused by the defibrillator paddles used to revive him. Rick had been brought back from the brink of death.

He had collapsed after a cyst ruptured in his leg. Not only did he have no memory of this event, he hadn’t even known about the cyst, which had silently grown to the size of an apple.

Somebody called an ambulance, though he would never find out who.

Rick had dealt with health issues in the past. He’d been living with diabetes, and there had been complications. He’d had a knee replacement a few years earlier. Still, nothing had prepared him for for the ordeal he was about to face.

Health Links & the Road to Recovery

For many patients, there are major bumps on the road to recovery. This has certainly been true for Rick O’Neil.

After he awoke, Rick quickly learned that his ruptured cyst had caused septic shock, resulting in kidney failure. He was transferred to The Ottawa General Hospital, where he received round-the-clock care. But new health problems continued to arise.

A month into his hospitalization, Rick’s care team discovered an ulcer.
The damage it had caused was extensive. “Basically, my stomach was gone,” says Rick. There was also a vascular problem – four clotted arteries in one leg.

By the time he was discharged, almost 6 months had passed. Rick had endured multiple surgeries and blood transfusions. He had stents in his leg, and was receiving a continuous dose of intravenous antibiotics.

Health Links – an initiative that provides better-coordinated care for the province’s most complex patients – was there to help. First, Rick was assigned a care coordinator: Laurie.

Laurie listened to Rick. She learned his recovery goals and care preferences, and she did everything in her power to ensure he received the medical and social support he needed.

But things were far from perfect. At home, Rick grappled with feelings of depression.

Two years earlier, he’d been living in Toronto with his wife and two children. He’d been working in communications, under the employ of some of Canada’s most high-profile organizations – including CBC and Bell Canada.

Since then, Rick and his wife had separated. His career and financial situation had changed. He moved back to Arnprior, the town outside of Ottawa where he’d grown up. It was during this transition period that his spate of recent health issues began.

The challenges in Rick’s life began to compound one another. Many of his problems stemmed from the fact that he now had limited resources, which meant no phone, no internet, and no car insurance.

How would Rick get to his doctor’s appointments? Given his situation, how could he make the lifestyle changes necessary for recovery?

The Difference Communication Makes

Laurie had made a huge difference in Rick’s life. But there had been limitations to what Health Links was able do. Due to logistics, it wasn’t always possible to provide patients like Rick with instant, continuous access to all of the care providers they needed to see.

Luckily, that was changing. The Arnprior Health Link had recently launched a pilot program that used technology to connect patients to those involved in their care – face to face, and in real time. That technology, of course, was Aetonix.

Rick was a good candidate for the pilot, so Health Links decision makers chose to include him. His life before and after this decision has been, in his own words, like “night and day”.

Equipped with the Aetonix digital tablet, patients can connect to anyone within their care networks, including medical practitioners, caregivers, and close family members. It’s as easy as tapping an on-screen image.

Rick used his tablet to connect to Laurie, as well as other health care providers at the Arnprior and Ottawa General hospitals. With the touch of a screen, he could see their faces – and they could see his.

“You can’t lie,” says Rick. His care coordinator watches to make sure he takes his medication. His doctor looks at him and can tell right away whether he feels as well as he claims.

Rick notes that, “with the tablet, you’re alone, but you’re not really alone”. Communicating with people like Laurie face-to-face helps patients understand that the professionals who support them truly care.

It also makes it possible to provide service in challenging situations. For Rick, travelling to see the physicians who treated him in Ottawa would be difficult and costly. Even walking to his care providers in Arnprior can be tricky – especially in bad weather. “Without the tablet, I wouldn’t be able to have doctor’s appointments,” he says.

These days, Rick is quick to acknowledge that Aetonix has saved his life.

Rick’s Message

Lately, Rick has been thinking about what happened to him. “I have a second chance at life,” he says. He wants to take the opportunity to help others. One of the best ways he sees of doing this is spreading the word about Aetonix.

“My situation is bad,” he says, “but there are people who are worse [off]”. Many of these people are seniors with limited mobility. They may have great difficulty getting around, which puts them at risk of missing important appointments.

Rick sees this situation playing out in Arnprior, and in nearby rural communities. He’s speaking up. “I’m from a small town,” he says. “There’s 35,000 people, and probably everybody knows about Aetonix now.”

He’s stood up and described the solution in church. He’s discussed it at length with people in the legion he sometimes visits to see live music. Wherever Rick sees a chronically-ill patient struggling to get by at home, he’ll step in to tell say there’s a better way to receive support.

But it’s not just those who require care that Rick wants to make an impression on. He also hopes his family will be proud of his will to help others. In a recent interview with Aetonix, he became emotional exactly once. He was talking about his children.

“I just want my kids to know…” here Rick broke off, choked up. But it was okay. From his tone of voice, it was clear what he meant.

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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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