Transition de soins

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Transition de soins

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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.

Better recovery

Un meilleur rétablissement

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

Une réduction du temps en hôpital

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

Length of stay

Efficiency

Efficacité organisationnelle

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

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L’interaction régulière que les patients obtiennent de ce produit nous aide, en tant que fournisseur, à s’assurer qu’ils aient 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

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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).