Remote care monitoring in Champlain LHIN offered to the francophone community

Objectives

• The Telehomecare COVID-19 and COPD Heart Failure Remote Monitoring Program delivered in French for francophones allows for the delivery of patient-centered care using innovative technology, expertly trained francophone nurses, and partnership with physicians.
• To support the francophone patient’s ability to self-manage their condition at home and decrease escalations to ER departments. This support is offered in their preferred language of French making the patient more comfortable and at ease.
• Provide francophone programs in a designated bilingual area that conforms with Home and Community Care Champlain’s designation as a bilingual organization.

Model

COVID Telemonitoring Program:

• App downloaded on the patient’s phone in French.
• If the patient does not have a cellular device, a Francophone clinician calls them two times per day to enter data on their behalf.
• The patient answers questions about their COVID-19 symptoms two times per day and enters their pulse oximeter temperature readings two times per day.
• The patient’s data is populated into the Vivify dashboard electronically and monitored by a Francophone clinician 7 days a week from 0800-2000 hrs.
• Francophone clinician responds to alerts generated by abnormal data and follows up with the patient
• Health teaching and symptom management completed with patient with escalation to primary care practitioner or ED if symptoms are deemed a crisis situation.

COPD, Heart Failure Telemonitoring Program:

• Six-month virtual program at no cost to patient to work on modifiable behaviors to manage their symptoms at home.
• At no cost to the patient, they are provided with integrated wireless biometric devices and a tablet with unlimited data.
• The tablet has text-to-speech capability and supports multiple languages.
• To support the patient’s ability to self-manage their condition at home, the self-directed program includes educational videos that are specific to their condition.
• The videos engage the patient in progressive behavior modification.
• The program was developed based on evidence-based guidelines that are reviewed annually.
• Using the tablet each morning, the patient collects and records their vital signs, weight, and oximeter reading, and answers a series of questions about their symptoms.
• The patient can contact our bilingual clinician by telephone, video call, text, and email seven days a week, between 0800 and 2000 hrs.
• The patient’s data in the app is monitored by a Francophone clinician who responds to system-generated alerts.

Francophone Clinician:

• Completes training modules to enhance health-coaching for patients with chronic conditions.
• Assesses a patient’s health index score daily and responds appropriately.
• Follow pathways and depending on severity of symptom(s), escalates as needed to primary care providers.
• Provides reports on a patient’s progress and health index scores to primary care providers.
• Completes a weekly check-in call with patients, including health coaching and review of their progress.

Technology Type: Virtual platform that allows remote monitoring RN to review patient biometrics and responses to questions on their symptoms immediately after the patient enters it into the tablet or phone app. This virtual platform also assigns the patient a health index score out of 100 alerting clinicians to patients requiring health coaching/symptom management. The virtual platform will also alert the clinician with flags, yellow and red, when biometrics or answers to questions on their health/symptoms are abnormal from the patients’ baseline.

Wireless biometric devices (BP cuff oximeter weight scale) and tablets are delivered to the patients’ home free of charge while they are on the program. For the COVID-19 program patient downloads an app on their phone.

Outcomes

• Supported 324 COVID-19 patients since launch on February 22, 2021, with 25 percent being served in French.
• COPD Heart Failure launched May 29, 2021. Since then, 32 referrals with 20% served in French.

Qualitative outcomes:
COVID-19 patients found that:

• Having a clinician available decreased the stress of managing their COVID-19 symptoms at home, as a clinician is a phone call away and able to support them.
• Eliminated the need to visit the Emergency Departments (ED) for COVID-19 symptoms as they were managed before the symptoms became a crisis.
• Patients learned how to manage COVID-19 symptoms at home and what their oximeter readings meant.

COPD Heart Failure Patients report that:

• Having a clinician available that speaks French makes them feel at ease as it is their primary language.
• Patients are supported at home and do not need to travel to participate in a COPD Heart Failure monitoring program.
• Patients reported understanding their symptoms and its correlations to their BP heart rate oximeter weight and medications.

Change Required to Support the Model

Telemonitoring is essential to maintaining patients at home and decreasing ED visits, therefore it is essential to provide Francophone services and programs in a designated bilingual area.

Adoption Rate

This model was used for 25% of COVID-19 Telemonitoring Program and 20% of COPD Heart Failure Monitoring Programs.