FOR REFERRING PHYSICIANS
As an extension of your primary care team, the Community Remote Care Management (CRCM) Program’s interdisciplinary professionals support you and your patients, helping to ensure the right work is in the right hands at the right time and place.
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The program serves:
• Patients with COPD and/or CHF (who may or may not have other comorbidities such as diabetes)
• You may refer your patients who live at home in Burlington and in surrounding communities.
The interdisciplinary team includes a Nurse Practitioner, Registered Practical Nurse, Community Paramedic, and support staff to assist with system navigation. Burlington Family Health Team (FHT) manages the intake process and the broader FHT interdisciplinary team is available to support patients when needed, surrounding them in a circle of care.
Patients receive access to Aetonix aTouchAway, technology already deployed at Joseph Brant Hospital. This proven system:
• Meets OTN requirements for privacy and security
• Is easy for patients to use their own provided devices
• Securely stores all biometric and questionnaire data
• Delivers alerts and regular reports to the patient’s CRCM team
• Gives the patient’s family and caregivers the ability to be virtually engaged as part of the circle of care.
The fit-for-purpose program tailors the team and the technology to meet the patient’s unique needs. CRCM patients are able to:
• Connect to their care team via messaging and virtual visits
• Respond to reminders and complete questionnaires
• Learn more about their condition through high quality educational resources
• Patients being monitored because of their chronic conditions are given a free tablet and biometric measuring equipment while they are enrolled in the program so they can:
- Measure and send current vital signs, biometrics, and symptoms to the care team
- Build self-management skills and confidence
• Intervention is triggered based on patients’ symptoms and biometric measurements. The CRCM team may initiate a phone call, video assessment, or home visit, or advise the patient to call 911 or go to the emergency department. Escalation protocols are based on the information provided by the referring physician and clinical standards.
Adjustments to the care plan can be made in real time with the NP-led model. When medical needs fall outside the scope of the consult model, the NP provides recommendations to the physician and/or connects directly with the physician on the spot. As the referring physician, you can feel confident about the care provided by the CRCM team. You will be notified (via fax for non-urgent matters or by phone if urgent) if your patient:
• Declines to participate during the intake call
• Has a change in medication (ordered by the NP)
• Has a significant and/or prolonged change in vitals • Has gone to the emergency department or has a prolonged period of hospitalization (2 weeks)
• Leaves the program
Coordination of care will also require your participation after a recommendation for imaging or lab work, referral to a specialist, initiation of a COPD action plan, or medication recommendation by the respiratory therapist.
Referral sources for patients with chronic disease:
• Primary care
• Other clinicians caring for this population
Making a referral is easy. Download the referral form, print it, and fax your completed form to 855 928 5284. If you have questions about referrals, please phone the intake line at 289 208 9619. The referral form is also available in Ocean eReferral.
The CRCM program provides comprehensive, continuing patient care from the safety of the home environment. Clinical care in the patient’s home reduces unnecessary calls to 911 and ED visits, and generally decreases face-to-face interaction with healthcare professionals, reducing the risk of infection of COVID-19 among vulnerable populations and healthcare providers. The program was designed by several partners of the Burlington Ontario Health Team (Burlington Family Health Team, Halton Paramedic Services, Joseph Brant Hospital, and HNHB LHIN Home & Community Care), and is based on two proven remote care programs already operating in Burlington. One sees Halton Paramedic Services supporting patients of Burlington FHT and Caroline FHT; the other is a remote support program for Joseph Brant Hospital patients following discharge. BFHT has a strong inter-disciplinary team consisting of an occupational therapist, pharmacist, dietitian, and respiratory therapist, as well as a team of mental health workers and physiotherapists, who are called in when needed to support the patient’s needs and build a coordinated care team for the patient and family.