Dr. Tia Pham, Site Lead Physician
South East Family Health Team, Toronto ON
Practising Telehomecare since 2008

Dr. Tia Pham, a busy family doctor at the South East Family Health Team in Toronto, has been actively engaged with the Telehomecare program since the pilot phase.  She continues to monitor 10 to 12 patients with multiple co-morbidities, many of whom are completely homebound and unable to travel to clinics, as well as patients who have been identified as high users of the emergency department and hospital.

Dr. Pham says that having patients use the home monitoring equipment, connected to a health coach who gets to know the patient well, “has helped my patients avoid Emergency, allowed us to efficiently adjust medications remotely without requiring the patient to come in for a visit, and react to patient concerns in a timely manner before their diseases become an emergency. The simple daily patient education component of the telemonitoring equipment has improved patients’ ability to manage their own health and chronic illness, which years of preaching in the office had not achieved previously.”

 

Kirandeep D Sidhu, Telehomecare nurse, William Osler Health System

“Focusing on the evidence-based practice has given me the confidence that the nursing care and health coaching we are providing in Telehomecare is the best available and results in the best health outcomes for our patients.”

 

John, family caregiver, and Katherine, Telehomecare patient

After John’s 93-year-old mother Katherine was rushed to Sunnybrook Hospital, he wasn’t sure what would happen next.

“She was admitted with Congestive Heart Failure and hospitalized for a week.  I just kept talking to everyone and asking questions about how to deal with this,” John says. “My mother lives on her own and I didn’t know what to expect, or how to help her.”

Fortunately, one of the nurses he approached – Jennifer – talked to John about Telehomecare and printed out a brochure for him. It was exactly the kind of help John was looking for. In his community, Telehomecare is provided by the Toronto Central Community Care Access Centre (CCAC).

“As a family caregiver, you don’t want to be a doctor – I’m a stock broker! — but you do want to be able to help your parent manage knowledgeably. Through Telehomecare, together we learned the signs and symptoms that meant she might feel worse and how to avoid them.”

Key to the experience was the CCAC Telehomecare nurse coach. “My mom bonded with her and really looked forward to her calls.” Taking daily readings was managed with the help of Katherine’s personal support worker (PSW). When the six-month Telehomecare program was approaching completion, John acquired home monitoring equipment that his mother still uses every day.

“Her PSW texts the results to me and enters them in a spreadsheet. When my mother goes for her regular visit to her doctor, she takes the spreadsheet with her.”

John says that hospital trip and her CHF are distant memories now. “Thanks to Telehomecare, we’re on top of things so she won’t have a recurrence. I’m very grateful. ”