1. Shared System of Care (COPD/HF) Prototype Session 3
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Shared System of Care (COPD/HF) Prototype Session 3
Westin Wall Centre
May 7, 2012

2. 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)
Identifying patients earlier who have COPD using a case-finding approach
Developing relationships and care plans amongst family physicians, specialists, patients, and community services 
Implementing more standardized referral and consult letters, and improving  relationships, hand offs, and communication between GPs and specialists
Improving the management of COPD by putting the GPAC guidelines into practice    

3. 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

4. PSP Prototyping Process and Timelines
Ideas have broad evidence of achieving aim
Develop Ideas
Implement and Spread Ideas
PSP Shared
Care COPD
LS1 AP
LS2
Test Ideas
Expert
Meeting
Ideas with some evidence of achieving aim
Ideas perceived as new
Strategy for change
LS3
LS2
Ideas for change AP AP
LS1
Expert
Meeting
PSP Shared Care HF/COPD
Mar’ May ’ May’13

5. Man, Sin, Ignaszewki, Man 2012

6. 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

7. 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 Chest

8. Patient Voice

9. Table Introduction and Roles
Dr. Gordon Hoag

10. 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

11. Shared System of Care (COPD): Innovations and Support
Part I

12. Break
(15 minutes)

13. Shared System of Care (COPD): Innovations and Support
Part II

14. Lunch

15. Heart Failure Shared Care
Dr. Sean A. Virani
Dr. Bruce Hobson

16. 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

17. Heart Failure in BC
Ministry Data 2010

18. 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

19. Projected Annual Incident HF Hospitalizations in Canada
Number of Cases
ADHF Diagnosis
Year
Johansen L et al., Can Journal of Cardiol

20. HF Readmissions Lee DS et al. Can J Cardiol 2004;20(6):599-607.
2007/2008 Readmission with Heart Failure 1,004 Heart Failure Episode 9,433 Readmission rate: 11%,
2008/2009 Readmission with Heart Failure 1,041 Heart Failure Episode 9,546 Readmission rate 11% ,
2009/2010 Readmission with Heart Failure 990 Heart Failure Episode 9,456 Readmission rate 10%
2010/20111 Readmission with Heart Failure 10,100 Heart Failure Episode Readmission rate 1,110 11%
Reference:
1. Lee DS et al. Regional outcomes of heart failure in Canada. Can J Cardiol 2004;20(6):
Lee DS et al. Can J Cardiol 2004;20(6):

21. Survival After Admission to Hospital for Heart Failure in BC 20 40 60 80
100
50% survival at 30 months
Months
Percentage Alive

22. 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
Months
Cleland and MacFadyen, 2002

23. 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

25. Heart Failure Therapies
Therapy
Agent
Reduction in 1° Endpoint
Self Management
23%
Pharmacological
ACE-I
8% - 26%
Beta Blocker
23% - 65%
Spironolactone
35%
ARB
15%
Device
ICD
23% - 31%
CRT
24% - 36%

26. Evidence Based HF Therapies in BC

27. 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

28. 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

29. 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

30. 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

31. Topics for Treatment Guidance
Risk Factor Management
Underlying Disease Management
Patient Self Management
Tele-monitoring
Pharmaceutical Treatments
Co-morbid disease management
Interventional Therapies

32. 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

33. 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

34. 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

35. Provincial Heart Failure
Strategy/ Network
Provincial HUB Team:
Bonnie Catlin: Provincial HF Clinical Nurse Specialist
Andy Ignaszewski: Medical Director
Janis McGladrey: Administrative Director

36. 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

37. Provincial
Hub:
Acute
HF Program
SPH
VIHA
RJH
HFCs
CDMs
Intern
ists
IHNs
Spec
GPs
Interior
KGH
Northern
PGH
Regional Centres
Additional Diagnostics
Specialist Services
Medication titration
Research
Specialist GPs
Special training in HF Management
Up to date with guidelines
Care of pts with chronic diseases
Staff able to provide guideline based care
Heart Function Clinics
Cardiologist with dedicated staff
Guideline driven care
IHNs/ICCs
Group practices with specialized training
VCH
Cardiologists/
Internists
VGH
Fraser
RCH
Surrey
Acute HF services
Clinical support
Guideline Development
Education
Patient
Primary Care
Cardiologists/Internists
Guideline driven care
Service Model
Care model is based all the principles of the expand Chronic care model to ensure integration into primary care, pt self management of their HF condition, provincial resources, policies, decision support tools, guidelines,

38. 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

39. BC’s Heart Failure Website www.bcheartfailure.ca
BC’s HF Network website
Central repository for all HF pt and health care professional resources, tools, guidelines etc.

40. 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

41. 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.)

42. Referral Resources Referral to a HFC Heart Function Clinic Form
Indications for
Referral
to a HFC
Heart
Function
Clinic
Form
DISCUSS HOW TO INTEGRATE THEM INTO THEIR OFFICE

43. Patient History/Assessment
Heart Failure
Patient
Questionnaire

44. A Guide to HF Patient Assessment
Patient Assessment Form

45. Snap shot
of patient
visit

46. Patient Education Resources
Heart Failure 101

47. Patient Education Resources
Heart Zones

48. Patient Education Resources
Daily weight

49. Patient Education Resources
Sodium Restriction

50. Patient Education Resources
Fluid Restriction

51. Patient Education Resources
Activity 51

52. Heart Failure Patient E-Learning Module
PAM WE NEED TO ADD THE SCREEN SHOT THAT HAS CSBC AND IHA LOGO ON IT, THERE IS ALSO A SHOT THAT HAS THE HF NETWORK ,CSBC AND IHA LOGO THAT WOULD ALSO BE GOOD. I THINK ITS IMPORTANT TO ACKNOWLEDGE IHA.

53. Guide to caring for your HF patients
Primary Care Physician HF Pathway: 3 options:
Step management
Still symptomatic
Start treatment

54. Partners in Care – FP / SP Attachment or Referral Project
Funded Sites
Sites Under Development
Partners in Care – FP/SP Attachment or Referral Project
Over 1500 FP’s and 125 SP
Respirology; Cardiology; Nephrology; Endocrinology; Psychiatry; Geriatrics; Neurology; GI; Orthopaedics; Rheumatology; Infectious Disease; General Internal Medicine; General Surgery; Radiology.
Funded Sites
Providence (Vancouver Division)
South Okanagan
Central Okanagan
Salmon Arm
Kootenay Boundary
South Vancouver Island
Northern MD’s
Fraser NW
East Kootenay
Richmond
Cowichan
North Shore
Sites Under Development
Fort St John
Langley
Georgia Strait
Mission
Abbotsford
WhiteRock/South Surrey
Chilliwack

55. Putting it all Together
Heart Failure
Putting it all
Together

59. Workflow

60. Workflow and Stepped Care

61. Stepped Care

64. docbruce@telus.net RACE
Local

65. Table Discussions

66. 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?

67. Lunch