Telehomecare for COPD and heart failure

A six-month health coaching and remote monitoring program, free for your patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure.

Telehomecare for Organizations | Remote Care Management: Content

How Telehomecare works

Telehomecare complements the care provided by the patient’s primary care provider and specialized care providers. With a kit that includes a blood pressure monitor, pulse oximeter, and weight scale, patients measure their vital signs at home and answer simple daily questions via a tablet about how they are feeling. Specially trained nurses monitor the results. Weekly telephone coaching also supports patients and their caregivers to understand how factors like diet and activity affect the way they feel. The goal is to support patients and their caregivers to take actions and steps to improve their symptoms and reduce exacerbations. Providers can receive regular reports on a schedule they prefer. Telehomecare processes and protocols are based on best practice guidelines including those of the Canadian Thoracic Society, the Canadian Cardiovascular Society, and the Registered Nurses’ Association of Ontario (RNAO). Telehomecare is recognized as a Best Practice Spotlight Organization (BPSO) program through RNAO.

OTN is a Best Practice Community Partners (BPSO) Designate on behalf of the Telehomecare Program.  The BPSO recognizes partners of the Registered Nurses’ Association of Ontario (RNAO) for the successful implementation of clinical best practice guidelines.  Read more

How Telehomecare is delivered

Telehomecare is available in nine of 14 Local Health Integration Networks (LHINs). The LHINs lead the program in each region and select host organizations to deliver the nursing services and coordinate the patient equipment. Equipment rental fees apply per patient enrolled. Host organizations may be hospitals, home and community care or other health care teams.

The program is appropriate for:

  • Patients with a diagnosis of mild to moderate COPD and/or congestive heart failure
  • Patients/caregivers interested in learning more about their condition
  • Patients/caregivers willing to use simple technology to capture their vitals and answer health questions on a tablet
  • Patients/caregivers committed to working on making behaviour changes to positively influence their condition

Refer your patient by completing, then faxing the LHIN-specific forms below. Telehomecare nurses may need provider assistance setting up a care plan. Patients can also refer themselves to the program.

Telehomecare is co-funded by the Ministry of Health and Long-Term Care and Canada Health Infoway.

Any Ontario physician can refer a patient to the program at the following Telehomecare sites.

The impact of Telehomecare

Telehomecare complements the care patients receive from providers and maintains the momentum of positive behaviour change in between office visits. It is a preventative, upstream approach to addressing chronic disease management that empowers patients and caregivers to learn about their condition and manage it confidently.

Telehomecare also has a significant impact on system utilization. An evaluation of patients enrolled by the William Osler Health System (Central West LHIN Telehomecare Program) showed that Telehomecare demonstrated a 70 per cent reduction in ER visits and a 76 per cent reduction in hospital admissions compared to pre-Telehomecare, at “graduation” and six months later.

In addition to reducing unnecessary ER visits and hospitalization, it increases access to non-urgent care and provides an effective and efficient ‘connected care’ journey for patients.

Other digital self-care programs in Ontario

There are other digital self-care programs available in Ontario. Learn more by clicking on the links below.

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