Chronic Disease Management

Able to do Virtually

RNs have skills in supporting patients with chronic illness of many kinds. They can provide patient education, working with patients on proactive care planning, goal setting, symptom management, health maintenance, lifestyle changes, and follow up. Much of these tasks are well suited to being done virtually. Some may benefit from video, but many can be done on the phone.

There are many chronic diseases that RNs can support from common (e.g. diabetes, COPD, hypertension, cardiac disease) to less common. It is beyond the scope of this document to provide specific guidelines for all chronic diseases.

Generally, however, in a virtual patient visit, RNs review patient goals and care plans, recent results in the health record, assess symptoms, monitor for exacerbation, medication therapeutic effect and side effects, discuss with the patient their level of knowledge, how they are managing and where they need help as well as more generally assess social/environmental status (live alone, finances, insurance coverage, key social determinants of health and health inequities).

Able to Do Virtually with Modifications

Much of the screening / monitoring for chronic health issues may be accomplished or coordinated through virtual care, however, some may require physical exam. Consider which patients require these assessments and how frequently. Some can be deferred on a case by case basis. Encourage patients to be engaged in their care by completing some measures at home where appropriate and possible (weight, waist circumference, etc.).

Not Able to Do Virtually

Specimen collection, including venipuncture (with appropriate orders) and physical exam (e.g. foot exam, etc.) would require face to face visit if being completed at the clinic.

Able to do Virtually

RNs can promote self-management through patient education and linking to various online resources.

This would, of course, be done in a patient centred manner, assessing patient’s understanding of their health status and creating goals of care together and discussing treatment options and involving client and care partners in decision-making and self-management.

VIDEO MAY HELP: Some treatment options may be better explained with visual presentation.

Able to do Virtually

RNs can provide virtual support to patients with mental health and substance use issues. This could include patient centred, proactive mental health counselling support, substance use counselling as well as crisis support. Anticipatory care and supportive counselling is crucial during this time of isolation. Be sure to include discussions around mental health, safety, and management of health concerns. Primary care RNs can also manage community referrals and coordinate treatment applications, follow up etc.

Able to Do Virtually with Modifications

Many activities such as conducting safety assessments, providing supportive counselling, life skills programming and goal planning in collaboration with client and other providers and develops appropriate safety planning can be done in virtually; however, there may be concerns with significant mental illness (e.g. mental health decline, self harm, overdose prevention, intimate partner violence, etc.) and these may trigger need for in-person care or coordination with emergency services.

Able to do Virtually

RNs are well suited to provide virtual support for smoking cessation, taking a whole person approach to understanding drivers and possible solutions. Given that we know smokers are at higher risk for severe complications if they contract COVID-19 and that smoking cessation for at least 4 weeks may be protective, this is a powerful opportunity to support patients in their desire to quit.

Smoking cessation counselling, education on options, and motivational interviewing are all important

and can be applied virtually. Medication options can be reviewed with the RN and coordinated with pharmacy and / or physician.

Able to do Virtually

With some practice, RNs are likely able to provide a significant amount of uncomplicated wound care virtually. This could include reviewing self-care of wounds, assessing symptoms, and providing wound care education(e.g. infection control, signs to look out for if worsening) to the patient and / or their caregivers. Also wound care planning / referrals / navigation for additional care can all be done virtually. (1,6)

Basic skin and wound care by patient or caregiver can be reviewed virtually.

VIDEO MAY HELP: Both assessment and self-management coaching may benefit from video. Being able to see the wound is critical for assessment. TIPS: good lighting is critical, patients could be need a window to get better light and colour. Patients could securely share photos, prior to the visit at these are often easier to assess due to higher resolution.

For education, the RN can demonstrate on video and the patient / caregiver can practice with virtual supervision.

Able to Do Virtually with Modifications

Full wound assessment such assessing limb perfusion, probing for wound depth/tunneling, etc., may necessitate an in-person visit periodically.

Not Able to Do Virtually

Complex skin and wound care as per BCCNP Standards  would need to be completed in person.NOTE: If the patient requires in-person wound care, a pre-visit done virtually can minimize the duration of face-to-face contact.

Go back to the guide

Triage and Assessment

Health Education

Health Promotion & Disease/Injury Prevention

<Chronic Disease Management

Care Coordination

COVID-Specific Care

 

Legend

Able to do Virtually
Able to do either on phone or video with reasonable confidence that for most clients you would achieve similar quality of care.

Able to Do Virtually with Modifications
There may be limitations to performing the task virtually. Video may be preferable to phone or significant modifications are required that limit the quality of care.

Not Able to Do Virtually
Not able to perform task virtually. May require in-person assessment or intervention.