How To Improve Remote Patient Care for Patients With Heart Failure

Heart failure is a chronic condition in which the heart does not function well enough to meet the demands of the body, which can lead to several health complications. It’s estimated that 600,000 Canadians, and 6.2 million Americans, live with the illness. This condition has a higher mortality rate than many other chronic illnesses, and if left untreated or poorly managed, severe or fatal health complications can occur.

In order to improve care for patients living with heart failure, one of the most important things healthcare providers can do is ensure their patients are regularly managing and monitoring their condition. Through telemedicine tools such as remote patient management systems, healthcare providers can effectively monitor, assess, and help patients improve their health.


Feamle doctor checking patients vitals

Steps You Can Take To Improve Care for Patients With Heart Failure

As with any chronic illness, each individual patient’s condition will present unique challenges. Not only are everyday symptoms difficult to live with, but staying on track with the necessary treatment and management can be a struggle for many. With traditional remote care, staying connected with patients and keeping them motivated can also present challenges.

In order to keep patients on the right track, and improve their overall care, healthcare providers can utilize telehealth tools that facilitate total remote patient management. Here, we will cover some of the key benefits of remote patient management, and the steps healthcare providers can take to improve care for those living with heart failure.

Use Remote Management To Identify Early Warning Signs

Female doctor on tablet

Patients living with heart failure often have complicated health needs. In order to meet these needs, it is important that healthcare providers are up to date on current symptoms and changes in their patients’ conditions. With traditional remote care, patients are typically given monitoring equipment, which can be used to detect pressing changes in their condition from their own home. Common equipment for monitoring cardiovascular diseases such as heart failure includes implantables, biosensors, blood pressure cuffs, pulse oximetry, and more.

While remote patient monitoring equipment has been shown to help drastically in identifying health changes quickly, it is important that the data from this equipment is fully utilized to improve a patient’s overall care. With complete remote patient management, these changes can not only be identified and delivered to a patient’s healthcare provider, but can also trigger automatic responses from the remote management system and deliver valuable insights to patients and other members of their care circle. In turn, patients can begin making adjustments to their care routine immediately, which can make all the difference in improving their health outcomes.

Provide Patients With Educational Resources To Help Them Self-Manage Their Illness

Patient reading resources at home

When treating patients with heart failure, educating them on the various aspects of their condition, and making sure they are aware of their responsibilities, is essential to keeping them on track with their health goals. One of the most effective ways of achieving this is through providing educational resources that can be easily accessed by patients where, and when they need them.

Educational resources can include heart failure books, pamphlets, newsletters, and media resources such as audio or video, which can all be provided or recommended via remote telehealth platforms. Through platforms such as aTouchAway, which facilitate remote patient management, educational resources such as these can be provided upon a patient request at any time, or can be automatically distributed to patients based on their health reports. By making sure patients have access to these resources, healthcare providers can ensure they are equipped with the most up-to-date knowledge for managing their illness.

Reduce the Patient’s Number of In-Person Healthcare Visits

When it comes to long-term management for heart failure, it is important that patients and their healthcare providers are on the same page. With traditional methods of care, and with some methods of remote care, frequent in-person healthcare visits are required to assess patients. This can be inconvenient for many patients, especially when they are required to travel long distances for brief visits. Furthermore, travelling to and from in-person appointments can present financial burdens for those living in remote communities, and can be difficult for those living with complex health conditions.

With remote patient management, healthcare providers can seamlessly connect with patients through video conferencing, phone calls, or secure messaging, depending on patient preferences. During the last year, many patients have become accustomed to the benefits of such appointments. A recent survey found that 42% of adults reported using telehealth services such as virtual appointments since the beginning of the pandemic, and 65% of patients who enjoyed the experience say it’s due to virtual appointments being more convenient than in-person visits. By providing virtual visits as an option, healthcare providers can ensure patients living with heart failure are able to benefit from advancements in healthcare technology.

Continuing To Improve Remote Patient Care

Nurses talking in hospital

As heart failure requires life-long management for the majority of patients living with the illness, it is important that the ways in which they receive care are effective, convenient, and practicable. By utilizing remote patient management tools such as integrated monitoring equipment, easy-to-access educational resources, and virtual healthcare appointments, healthcare providers can continue to motivate patients and improve overall health outcomes.

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

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
COPD Education – Continuous Maintenance


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

Patient, Educator (Nurse, RT or Physician)

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 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).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

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.
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