Presentation is loading. Please wait.

Presentation is loading. Please wait.

Shared System of Care (COPD/HF) Prototype Session 3

Similar presentations

Presentation on theme: "Shared System of Care (COPD/HF) Prototype Session 3"— Presentation transcript:

1 Shared System of Care (COPD/HF) Prototype Session 3
PSP master PowerPoint template specifications Font throughout: Myriad Pro Title font colour: RGB All text font colour: RGB Title slide: Title: 44 font Speaker: 32 font Place and date: 20 font Content slide (positions from top left corner): Title: 32 font; title text box: horizontal 0.56” vertical 0.25” Main text box: horizontal 0.56” vertical 0.25” Footnote: 12 font; horizontal 0.56” vertical 7.25” Font sizes and bullets: see slide 2 PSP slide master specifications Title and ending slides Position of graphics and text from top left corner: Top graphic: horizontal -.01” vertical 0.05” Bottom graphic: horizontal 0” vertical 8.16” PSP logo: horizontal .84” vertical 1” GPSC logo: horizontal 4.49” vertical 7.19” Master title: horizontal 0.56” vertical 3.5” Speaker: horizontal 0.56” vertical 5.08” Date and place: horizontal 0.56” vertical 5.92” Information box: horizontal 1.64” vertical 3.17” Main slides: PSP logo: horizontal 9.28” vertical 7.18” Page number: horizontal 10.14” vertical 7.72” 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
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

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




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

Download ppt "Shared System of Care (COPD/HF) Prototype Session 3"

Similar presentations

Ads by Google