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Telehomecare nursing

Telehomecare is a six-month program to help patients with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF) through remote monitoring and health coaching from Registered Nurses. 

The goal is that patients, within a supportive, at-home environment, learn about managing their condition, recognize early warning signs, and are supported with digital monitoring of vital signs.

WHO IS ELIGIBLE?  

Patients with a COPD or CHF diagnosis who would be comfortable using simple, in-home monitoring equipment.

HOW DOES THIS PROGRAM WORK?

  1. Eligible patients receive a touch-screen tablet to complete daily reports, plus training and equipment to check their own blood pressure, pulse, heart rate and weight on a daily basis. This information is digitally sent to Registered Nurses.  
  2. Registered Nurses review each patient's daily monitoring signs (Monday to Friday). Abnormal vital signs are flagged, and addressed with the patient and physician as appropriate. 
  3. There is an option for sending a monthly data report to the patients' physician.
  4. Eligible patients also participate in a weekly health coaching phone call with a Registered Nurse geared to their specific situation. Topics may include: understanding the daily measurements, their condition and its symptoms, medications, self-monitoring, and action planning for better health. 
  5. Typically after six months, a Registered Nurse completes a discharge assessment and maintenance plan to share with the patient and their physician, and may also provide links to other community resources.

BENEFITS:

Telehomecare patients gain skills to manage their condition at home and, on average, experience 50% fewer hospital visits after "graduating" from the program.

MORE INFORMATION:

TO BE REFERRED TO TELEHOMECARE:

  • Please discuss with your doctor or primary care provider.
  • Patients can also refer themselves by calling the Central LHIN at 416-224-2863 or
    1-844-232-2882

Telehomecare has helped over 14,000 patients since it was launched in 2012. It is supported by Ontario Ministry of Health and Long-Term Care, Canada Health Infoway and Ontario Telemedicine Network (OTN).