When people with long term health issues transition from illness to health, or move from hospital to home after an exacerbation they feel vulnerable, unsafe, uncertain, lost, and unsupported. Transitions are life experiences that result in change. Telehealth gives easier access to care and increases patient involvement and self-awareness for self-care and improved outcomes. The purpose of our research was to explore how telehealth tools and processes lend themselves to nursing of patients through transitions.

Methods: A multimethod study with before and after questionnaires consisting of validated questionnaires. These were triangulated with nurse field notes, nurse assessment of each participant, exit interviews with participants, and questionnaire for referring clinicians about their experience of the service. Twenty patients, their five doctors, and two telehealth nurses, participated.

Results: PACIC questions revealed that participants felt more involved in decision making, self-care planning, referrals to other services, and understood more clearly their health issues. The Quality of Life questions showed improvement, and their health issues bothered them less after telehealth. The Perceived Health Competence questions showed an improvement in how they rated their health, and their ability to influence their health. Clinicians indicated that the service worked well, was appropriate and useful, and should continue. The interviews revealed that participants learned how to do self-care with insight, made the transition from hospital to home and from illness to a new way of being well, and referred the service to others like them.

Discussion and conclusion: We conclude that our experienced nurses used the tools of telehealth (monitoring of self-care and videoconferencing) to coach, supervise, guide, and accompany patients through an organizational transition for half our participants (from hospital to home) and all the participants through an illness to a new way of being well.