Cercles bleus

Transition de soins

Un couple d'aînés en transition de soins se tenant l'un l'autre heureusement

Lorsqu’un patient transitionne de l’USI à un autre département, puis de l’hôpital à la maison, la continuité est essentielle. Nous aidons les hôpitaux à offrir aux patients une transition fluide en permettant aux professionnels et aux fournisseurs de soins d’être connectés et coordonnés.

Deux médecins révisant les données de rétablissement sur un téléphone mobile.

Un meilleur rétablissementIcône Rafraîchir

Des plans clairs de continuité des soins soutiennent un meilleur rétablissement et accentuent l’engagement du patient.

Une réduction du temps en hôpitalIcône d'éclair

Avec un programme en place pour assurer la continuité, les patients peuvent effectuer une transition plus tôt, sans déranger leurs soins établis.

Illustration de gens révisant l'heure, le calendrier et le sablier représentant une diminution de la période en hôpital des patients étant donné leurs transition sans dérangement de leurs soins.
Médecin en tenue civile utilisant Aetonix Systems pour communiquer les changements dans un formulaire avec ses collègues et augmentant l'efficacité organisationnel.

Efficacité organisationnelleIcône médecin

Une communication améliorée entre le personnel minimise la perte de temps et optimise le temps passé à offrir les soins.

Ce que nos clients disent de nous

Évaluation cinq étoiles

L’interaction régulière que les patients obtiennent de ce produit nous aide, en tant que fournisseur, à s’assurer qu’ils ont la meilleure expérience de soins tout en renforçant le fait que les soins ne doivent pas cesser au seuil de la porte d’hôpital.

Dr. Daniel Cornejo Palma, MD

Résident Chirurgie Générale, Women’s College Research Institute

Carré d'étude de cas. Apprenez-en davantage sur la manière dont Aetonix à aider d'autres organisations. Cliquez pour lire l'étude de cas.

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Groupe d'appareils de surveillance de santé, telles une balance numérique, des montres, une machine de pression sanguine et une tablette et téléphone intelligent ayant l'application aTouchAway ouverte.
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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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