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Shared System of Care (COPD/HF) Prototype Session 3. Westin Wall Centre. May 7, 2012. Aim – Why are we here?. To collaborate to create a shared system to improve the quality of care and experience for patients at risk for, and living with, COPD and/or Heart Failure (HF). Achievements to Date.

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Presentation Transcript
aim why are we here
Aim – Why are we here?

To collaborate to create a shared system to improve the quality of care and experience for patients at risk for, and living with, COPD and/or Heart Failure (HF)

achievements to date
Achievements to Date
  • COPD-6 case finding
  • Smoking Cessation Renaissance
  • Collaboration amongst GP, Respirologists and RTs, Divisions, and/or Partners in Care
  • PSM and Exacerbation plan – including the RT providing patient education
psp prototyping process and timelines

Ideas have broad evidence of achieving aim

PSP Shared

Care COPD

Ideas with some evidence of achievingaim

LS2

AP

LS1

Expert

Meeting

Ideas perceived as new

Develop Ideas

Implement and Spread Ideas

Test Ideas

Strategy for change

PSP Prototyping Process and Timelines

LS3

LS2

Ideas for change

AP

AP

LS1

Expert

Meeting

PSP Shared Care HF/COPD

Mar’11 May ’12 May’13

copd and ihd
COPD and IHD
  • One third of patients with angiographically proven CAD have COPD
  • Common mechanistic pathways:
      • Accelerated aging
      • Oxidative stress
      • Inflammation

Man, Sin, Ignaszewki, Man 2012

the complex relationship between ischemic heart disease and copd exacerbations
The complex relationship between ischemic heart disease and COPD exacerbations
  • “There is merit in establishing a combined cardio respiratory team to deal with these highly complex patients, so that heart failure specialists and respirologists can put there knowledge together to advance care for such patients.”

Man, Sin, Ignaszewki, Man 2012. Chest

table discussion
Table Discussion
  • Introduce yourself and how you are involved with patients with COPD and/or Heart Failure?
  • Identify what you hope to get out of the prototype session today to improve the care of patients with COPD and/or Heart Failure in relation to creating a shared system of care
slide12
Break

(15 minutes)

slide15
Heart Failure Shared Care

Dr. Sean A. Virani

Dr. Bruce Hobson

outline
Outline
  • Heart Failure in BC
    • Care gap
  • Aspects of Heart Failure Shared care
    • Novel treatment processes and pathways
  • Provincial Heart Failure Strategy/Network
  • Provincial HF tools and resources
  • Discussion/Questions
heart failure in bc
Heart Failure in BC

Ministry Data 2010

prevalence of heart failure
Prevalence of Heart Failure
  • Estimated 10M in 2037
  • Incidence:
    • 550,000 new cases/yr
  • Prevalence:
    • 2% in 40 – 60 year olds
    • 10% in those aged 70+
    • adapted from McMurray and Pfeffer, 2003

10.0

Patients in Millions

4.8

3.5

1991

2001

2037

Year

projected annual incident hf hospitalizations in canada
Projected Annual Incident HF Hospitalizations in Canada

Number of Cases

ADHF Diagnosis

Year

Johansen L et al., Can Journal of Cardiol

hf readmissions
HF Readmissions

Lee DS et al. Can J Cardiol 2004;20(6):599-607.

survival after admission to hospital for heart failure in bc
Survival After Admission to Hospital for Heart Failure in BC

100

80

50% survival at 30 months

60

Percentage Alive

40

20

0

0 5 10 15 20 25 30 35 40 45 50

Months

http://www.healthservices.gov.bc.ca

heart failure is a malignant disease
Heart Failure is a Malignant Disease

100

Breast Ca (adjuvant tamoxifen)

80

SOLVD treatment (on enalapril)

60

Percentage Surviving

Metastatic Prostate Ca

40

20

Lung Ca

0

0 6 12 18 24 30 36 42 48 54 60

Months

Cleland and MacFadyen, 2002

heart failure stats
Heart Failure Stats
  • 89,343 reported with HF in BC

in 2009/10 at a cost of

$589,973 M/year

    • Hospital cost ~$338 M
    • MSP cost ~$1480 M
    • Pharmacare ~$102 M
  • HF is the most common cause of hospitalization of people > 65 years of age
  • Average 1 year mortality rate of 33%
  • Improved management can avoid as much as 50% of inpatient HF related admissions
  • In 2009 existing HF clinics provided service to approximately 1.5% of HF patient population
the care gap
The Care Gap
  • Efficacious evidence based therapies have not been consistently integrated into clinical practice
    • Barrier to better outcomes in HF patients
    • New therapies continue to roll-out
  • Heart Failure Process of Care Measures (IMPROVE-HF)
    • Associated with improved outcomes in HF patients
      • ACE/ARB, BB, ICD/CRT, aldosterone anatagonist, HF education and anticoagulation for AF
    • Strategy for implementation of best practices
      • Provincial HF Strategy and PSP
hf shared care
HF Shared Care
  • Complexity of the disease process necessitates a collaborative and shared approach to patient care
  • Specific responsibilities for the primary care provider and the specialist
  • Standardized with established “hand offs”
  • Broadly applicable across may patients
  • Patient centered
  • Consistent process and clinical care pathways
  • Same vocabulary
  • Understanding of patient progress through treatment arc
  • Seamless reporting
highlights
Highlights
  • Application of Evidenced-Based Guidelines
  • Best Practices distilled into an operational model
  • Designed for busy office practice
  • Specialist Guided, GP Managed Care
  • Clinical decision support
  • Care maps and GP-Specialist interactions
consistent care model
Consistent Care Model
  • Consistent approach to care, tailored to local needs
  • Developed by a multidisciplinary team
    • GPs, Cardiologist, NP, RN, Rx, dietician, etc..
  • Patient and provider milestones
    • Continuous specialist guidance and support available through the PSP life cycle and beyond
  • Guidance will include:
    • Targets/Goals for treatment and response
    • Care Management Decision Points
    • Programmed Pathway Actions
topics for treatment guidance
Topics for Treatment Guidance
  • Risk Factor Management
  • Underlying Disease Management
  • Patient Self Management
    • Tele-monitoring
  • Pharmaceutical Treatments
  • Co-morbid disease management
  • Interventional Therapies
dynamic adjustment
Dynamic Adjustment
  • Integration of new information and co-morbid conditions into plans of care
  • GPs collect and coordinate multiple inputs
    • Diagnostic tests
    • Treatments
    • Plans of care from other providers
  • Pathways evaluate & adjusts care plan to account for new information
decision points pathways
Decision Points & Pathways
  • Pathways will define care steps & outline decision points
  • Decision Points may include
    • Intervention Types
    • Referral Pathways
    • Links to co-morbid disease management
    • Access to community resources
    • Patient self management
  • Care Management Model selected based on:
    • Underlying disease process and co-morbid conditions
    • Care plan for patient
care management models
Care Management Models
  • Self-Managed
    • Patient Education
    • Patient Action
  • GP Managed
    • Pathway
    • Information Exchange
  • HF Clinic
    • Multi-disciplinary Clinic Visit
  • Specialist Input
    • Cardiologist Input
    • Cardiologist Consult
slide35
Provincial Heart Failure

Strategy/ Network

Provincial HUB Team:

Bonnie Catlin: Provincial HF Clinical Nurse Specialist

Andy Ignaszewski: Medical Director

Janis McGladrey: Administrative Director

background
Background
  • Developed in collaboration with BC Health Authorities, and Cardiac Services BC
  • Established to address the current gaps in HF care and service across BC
  • Funded by Cardiac Services BC
slide37

CDMs

  • Care of pts with chronic diseases
  • Staff able to provide guideline based care

Primary Care

Spec

GPs

Spec

GPs

Intern

ists

CDMs

CDMs

VIHA

RJH

Spec

GPs

Cardiologists/

Internists

Intern

ists

Fraser

RCH

  • Regional Centres
  • Additional Diagnostics
  • Specialist Services
  • Medication titration
  • Research

Fraser

Surrey

IHNs

HFCs

VCH

SPH

Spec

GPs

CDMs

VCH

VGH

HFCs

Patient

Intern

ists

CDMs

Interior

KGH

IHNs

IHNs

Provincial

Hub:

Acute

HF Program

SPH

IHNs

HFCs

HFCs

Spec

GPs

Intern

ists

CDMs

Acute HF services

Clinical support

Guideline Development

Education

Northern

PGH

  • Specialist GPs
  • Special training in HF Management
  • Up to date with guidelines

IHNs

HFCs

  • Heart Function Clinics
  • Cardiologist with dedicated staff
  • Guideline driven care
  • IHNs/ICCs
  • Group practices with specialized training
  • Guideline driven care

Cardiologists/Internists

Guideline driven care

provincial heart failure strategy goals
Provincial Heart Failure Strategy Goals
  • Improve heath care professionals access to evidence based HF resources
  • Standardize HF care across the province
  • Improve access to heart failure diagnostics and HF specialist care
  • Decrease ER & hospital admissions
  • Facilitate patients’ HF self management
  • Facilitate shared care across the health care continuum
  • Decrease heath care costs
practice resources for hf psp
Indication for referral

Referral form

Patient Assessment

Pt questionnaire

Assessment form

Snap shot

Patient HF education

GP HF Pathway

Tools:

Created in collaboration with Provincial HF RDWG

Pathway:

Dr. Bruce Hobson in collaboration with HF Cardiologists and Provincial CNS

Over-arching philosophy

Practice Resources for HF PSP
overarching philosophy will guide the creation of all patient education material
Overarching Philosophy will guide the creation of all patient education material
  • Content must be in congruence with the most up to date HF evidence
  • Created in plain language
  • Must be patient centered
  • Must have patient input
  • Standard content
  • Develop key elements for each resource
  • At minimum each form must contain provincially standardized key elements
  • All health care professionals will teach the same content
  • Each tool/form is a one pager that can be individually printed, photocopied, or scanned.
  • Incorporate at least two alternate models of learning within each tool/form (eg. Narrative, visuals/pictures etc.)
referral resources
Referral Resources

Indications for

Referral

to a HFC

Heart

Function

Clinic

Referral

Form

patient history assessment
Patient History/Assessment

Heart Failure

Patient

Questionnaire

a guide to hf patient assessment
A Guide to HF Patient Assessment

Patient

Assessment

Form

slide45

Snap shot

of patient

visit

patient education resources3
Patient Education Resources

Sodium

Restriction

patient education resources4
Patient Education Resources

Fluid

Restriction

guide to caring for your hf patients
Guide to caring for your HF patients

Primary Care Physician HF Pathway: 3 options:

Step management

Still symptomatic

Start treatment

heart failure

Heart Failure

Putting it all

Together

slide64

docbruce@telus.net

RACE

Local 604 696-2131

1-877-696-2131

table discussions
Table Discussions
  • How would you integrate these resources into your office practice?
    • How can non-clinician members of the team help with the administration and completion of these tools?
    • How could you use these tools to create more practice efficiency?
  • Do you think the referral form is user friendly?
    • What are the key pieces of information that specialists would need to facilitate a meaningful consultation?
  •  What constitutes a good consultation letter from a specialist?
    • What are the key information pieces a GP would need included in the consultation letter they get back form the specialist?
    • What are the key pieces of information that primary care providers would need to ensure optimal patient care?
  • How would a structured management algorithm improve or enhance your care of HF patients?
    • How would this allow you to provide more evidence based care?