CareCoach® Chronic Disease Management

Helping People with Chronic Disease

Having a chronic condition like Type II  Diabetes, Heart Failure, C.O.P.D.  and Asthma is a full time job that impacts people in large cities and small rural communities alike. At Assistance Services Group we believe that since people are always dealing with their health problems then we should always be available to help. That is why we have created a 24/7 service designed to be there when we are needed most. 

By supporting patients and their formal and informal care networks we can help people access care regardless of when they need it or where they live.

Using Telehealth to Support Primary Care

Our model of disease prevention and self-management is based on the philosophy that telehealth will work best when it acts as a natural extension of the relationship between an individual and their family practice - what the Chronic Care Model refers to as the relationship between an informed activated patient and a prepared proactive provider team.

Our telehealth solutions can help convert episodic care processes into a care management program where the reach of primary care is extended both in terms of the time that care is available and the place where it is delivered. We can provide evidence-based outreach, support decision making and counsel for behaviour change all the while supporting the existing relationship between a patient and their primary care team.

Our Programs are designed to:

  • Make primary care available 24 hours a day and seven days a week
  • Identify people at risk for exacerbations, and increased utilization of healthcare resources
  • Support patient and family centred interventions
  • Increase patient engagement in and ownership of their care plans
  • Improve clinic work flow, virtually eliminating no shows, improving follow up and preventing unnecessary visits to the emergency department and unplanned admissions to hospital
  • Improve the efficiency of clinical practice thereby improving economic outcomes for providers

What We Do


The foundation of the Assistance Services Group primary care support program is our 24 hours a day, 7 days a week telehealth service.  By closely integrating our virtual care team with a primary care practice we can provide care and coping support for patients and their families.  Our care team will provide patient centred assessment, advice and system navigation using evidence-based guidelines and patient centred care plans that have been developed by the local team. Through secure integration we can also support advanced access and other innovative practice solutions. Finally by accessing and supporting a patient’s discharge plan we can help prevent unplanned readmissions.


By integrating to the patient’s EMR our team can help identify patients that meet guideline - based requirements for enhanced care.  We will then further stratify the patients to identify variables such as multi-morbidity, activation levels, and social determinants based challenges to care (e.g. poverty, literacy, housing, and transportation).Then working with the Provider team we will create interventions designed to optimize the patient’s care experience.


Using clinical guidelines and individual practice processes we will identify and support the monitoring of targeted patients.   This monitoring process can include mobile devices, tele-homecare solutions or simple text messaging or phone systems to capture key indicators such as medication adherence, weight, blood glucose levels, blood pressure, and oxygen saturation as well as to detect falls or other issues regarding activities of daily living. Assistance Services Group can provide monitoring and support 24 hours a day using a highly scalable and therefore cost effective solution. Our monitoring is turnkey solution  with our team managing the implementation and support of all devices used.


Our navigation service is designed to improve patient flow and access to services, within the clinic, after discharge from hospital and to those provided by the government and other agencies.  The core solutions involved in navigation are inbound call handling, automated reminders, follow up and community service referral. 

Inbound call handling

The Assistance Services Group team can support a busy clinic’s switch board either after hours or during peak times. With appropriate access we can help create appointments or provide clinical after hours support using registered nurses ensuring that all patients that contact the clinic are provided with appropriate referral and care that is inside of the provider network. This is designed with continuity of care in mind. 

Automated reminders and follow up

The automated communication systems provides secure voice and digital communication to help remind patients about appointments or routine follow up as well as providing a cost effective way to assess progress, capture vital signs, coach for behaviour change, provide patient education, and measure patient satisfaction. The communication is delivered without human intervention beyond routine use of the clinic scheduling system or initiation of patient centric care plans. Communication can be in the form of interactive voice response (IVR), text message, email or regular post. Users have access to evidence-based content through a secure connection to the Assistance Services Group on-line environment.

Service referral

Assistance Services Group maintains a service referral database so that callers and on-line users can access information on community services that are within the healthcare system as well as those programs that impact the social determents of health. (e.g. disease specific associations, housing, early childhood development, social assistance)


The Assistance Services Group CareCoach® program helps provider teams to reach out to patients and their families in between visits. This behaviour support program is an adjunct to counselling provided by in office staff.  Our CareCoaches follow evidence-based guidelines and provider developed care plans to enhance patient self-management. Using brief interventions and on line tools they employ motivational interviewing and cognitive behavioural counselling techniques to help people reach treatment goals.  Our CareCoaches also have access to a network of allied health professionals that can augment existing local resources as required.  All encounters are documented and shared with the patient’s provider team to optimize collaboration and continuity of care. Our CareCoach program employs a primary coach philosphy so that people get to know their coaches thereby enhancing outcomes.