TeleHomecaRe InterVention Evaluation Study

Inclusion Criteria: Patient: * The patient has a documented diagnosis of HF or COPD (with or without co-morbid conditions); * The patient has been classified as a 'heavy user' of the health care system, characterized by any of the following: * A minimum of one hospitalization for a respiratory or cardiac complaint in the past six months; * A minimum of two emergency department/urgent care center visits for a respiratory or cardiac complaint in the past six months; * Currently receiving nursing services via CCAC; * Frequent visits to primary care provider in the past year; * Patient/informal caregiver (if applicable) is an adult (over 18 years), able and willing to provide informed consent; * Patient/informal caregiver (if applicable) is fluent in English; * Patient/informal caregiver is able and willing to operate the Telehomecare equipment; and * Patient lives in a residential (private home or retirement home) setting with an active landline. In addition to the program eligibility criteria, the following criteria for the intervention evaluation study apply to recruitment of patients: * Patient must have a documented consent for participating in Telehomecare * Patients enrolled in the Telehomecare program must have agreed to share their contact and health information for evaluative purposes * Patients must provide informed consent before participating in observations, interviews, and surveys as part of the program evaluation study Healthcare Provider A healthcare provider that has: * Referred a patient that has been previously enrolled in the Telehomecare program, and/or; * Provided primary care to a patient enrolled in the evaluation study * Previously or currently participated in delivering Telehomecare as a provider or care administrator; o For observations, interviews, and surveys: nurses/physicians must have at least 2 months experience in providing care using Telehomecare Technicians, Administrators, and/or Decision Makers The following are eligible for inclusion in the study: * Technicians involved in the set-up of Telehomecare equipment in the patient home. * Administrators and/or decision makers of the Telehomecare program as a larger network of care such as Healthcare Program Managers, key members of the LHINs, OTN etc. Exclusion Criteria: Patient * Less than 18 years of age; * Individuals without an established diagnosis of COPD or HF * Unable or unwilling to provide verbal informed consent * Demonstrated non-adherence to the THC program: o The Telehomecare Nurse works with each patient on a case-by-case review to assess willingness to partner in their own care, and if the number of missed consultation appointments and reasons for demonstrate overall non-adherence with the program; * Inability or unwillingness to use Telehomecare equipment, and/or; * Do not have a regular caregiver to assist in the use of the equipment (if assistance is required) Healthcare Provider * Is not a practicing healthcare provider in any of the said LHINs Technicians, Administrators and/or Decision Makers * Unable or unwilling to provide verbal informed consent