How does it work?
Who is eligible?
What are the qualifications of the Telehomecare Nurses?
How does this service integrate with Primary Care?
How does the Telehomecare Nurse work with the existing care team?
What is Health Coaching?
What is Self-Management?
What is a Best Practice Organization?
What are Clinical Best Practices?

 

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How does it work?

Telehomecare is a patient self-management program that engages patients as partners in their care plan-right in their home.  Telehomecare nurses will remotely monitor their health status through the use of technology

Who is eligible?

To begin, patients with Chronic Obstructive Pulmonary Disease (COPD), Heart Failure (HF) and associated comorbidities can participate.

What are the qualifications of the Telehomecare Nurses?

Telehomecare registered nurses must be in good standing with the College of Nurses of Ontario. Previous experience and a strong knowledge base working with CDM patients are necessary, as well as background skills in adult education and case management.

Telehomecare Nurses will complete a rigorous education and training program which is evidence based, built on RNAO best practices and supported by subject matter experts in the fields of CHF, COPD, patient self-management and health coaching.

How does this service integrate with Primary Care?

Primary Care teams are essential to Telehomecare.  Primary Care teams helped to inform the Telehomecare care delivery model and address the realities of chronic disease management including:

  • Lack of follow-up in between office visits

  • Limited time and resources to manage patient needs

  • Repeated emergency room visits and hospital admissions

  • Lack of coordination and continuity of care

  • Medication adherence

How does the Telehomecare Nurse work with the existing care team? 

The registered Telehomecare nurse will partner with the patient's primary care team and other health care providers (i.e. specialists) to develop their care plan and keep them regularly informed of the patient's progress. Patients will continue to have appointments with their existing health care providers as required; Telehomecare is not a replacement for existing services.

What is Health Coaching?

Health coaching combines evidence-based techniques of motivational interviewing, goal-focused action planning, and problem-solving to identify and address a patient's individual barriers to change. Health coaching will help to build patient skills in self-reflection, decision making and planning to support health behaviour change.

What is Self-Management?

Self-management includes the tasks that patients with chronic conditions must adopt to live well and engage in activities that protect and promote health (i.e. healthy behaviours). Self-management strategies must be tailored toward the attitudes, beliefs, culture and preferences of the patient. The Telehomecare nurse establishes a therapeutic relationship that empowers the patient to take control of their own health.

What is a Best Practice Organization?

Best Practice Spotlight Organizations (BPSO®) are health-care and academic organizations which partner with the Registered Nurses’ Association of Ontario (RNAO) to facilitate the formal implementation and evaluation of clinical best practices.  OTN was awarded the designation of BPSO® Candidate on behalf of the Telehomecare Expansion Program.

What are Clinical Best Practices?

Clinical Best Practices are “systematically developed statements to assist practitioners and patients to make decisions about appropriate health care for specific clinical (practice) circumstances”. (Field and Lohr, 1990)  The integration of clinical expertise, patient values and preferences, and application of clinical best practices into clinical decisions enhances the opportunity for optimal outcomes and quality of life.