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COPD and Heart Failure Telehomecare Referral Form

Eligibility for Telehomecare Services
– Patient has an established diagnosis of Heart Failure or COPD (with or without co-morbid conditions).
– Patient has a fixed address and a phone.
– The patient is capable of managing monitoring equipment (BP and O2 monitors, scale). The patient is able to read and answer questions (yes/no multiple choice) using a computer tablet.
– Patient meets criteria for Virtual COPD clinic (CONFIRMED diagnosis of COPD with exacerbations leading to ED visit or hospitalization)