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COPD - From Discharge to Self-Management

Ann, 72, admitted for third time this year – acute exacerbation of her severe COPD
Discharge Plan: To improve how Ann responds to and handles exacerbations, she requires

Ongoing monitoring of medication adherence

Self-management education with an updated action plan shared with her primary caregivers/supports

Care coordination and symptom monitoring

Super Focus – 72 hrs. post D/C

As part of admission and/or discharge planning meeting – Ann and her daughter/caregiver signed up for MeU Care – app downloaded

Post D/C Day 1 – HIPAA Secure Chat with Ann/Caregiver

Personalized Intro “Selfie” video from inpatient CM:

Reminds Ann of d/c plan, s/sx to report& who to contact , explain hand-off to outpatient CM who will coordinate care, assist navigating the COPD program she is enrolled in

Education: Message includes attachment of d/c plan, follow-up appointments (scheduled, needing to be scheduled), COPD Action Plan, medication list and video demonstrating inhaler technique

Everyone has the same info, care can be effectively coordinated

Personalized Closing includes an action step for Anne:

Ann is given a specific action to perform related to the education Ann is asked to reply via chat to an open-ended question: “Let us know how you took your medication last evening and this morning?” Ann is given a specific action to perform related to the education
Ongoing Remote Monitoring: Chat

Ann/Caregiver will be instructed to send videos/photos of: inhaler use, walk cycle/Activity tolerance, doing breathing exercises, medications in home, breathing when she reports feeling more SOB or has cough, home safety, etc.

Reinforcing video education sent as needed (i.e. Video on proper inhaler use shared via chat)

Symptom monitoring via Digital Survey of COPD Zones with alert to providers for early intervention auto-sent on scheduling meeting patient’s needs/condition

Ongoing Education and Care Coordination: Chat

Education delivered as needed based on symptoms and ability to self-manage at any given moment in time

Patient, caregiver, PCP, Specialists, and more use chat to HIPAA securely communicate, coordinate, update care plan, intervene

Analytics: Real-time Data

All encounters saved in MeU Care and EHR and/or Care Management system to meet quality measures, compliance, reimbursement requirements

And so much more, please request a demo

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