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

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Presentation on theme: "Shared System of Care (COPD/HF) Prototype Session 3 Westin Wall Centre May 7, 2012."— Presentation transcript:

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

2 2 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) Aim – Why are we here?

3 3  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 Achievements to Date

4 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 Ideas for change LS3 AP LS1 AP LS2 Expert Meeting Mar’11 May ’12 May’13 PSP Shared Care HF/COPD

5 5 Man, Sin, Ignaszewki, Man 2012

6 6  One third of patients with angiographically proven CAD have COPD  Common mechanistic pathways:  Accelerated aging  Oxidative stress  Inflammation COPD and IHD Man, Sin, Ignaszewki, Man 2012

7 7  “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.” The complex relationship between ischemic heart disease and COPD exacerbations Man, Sin, Ignaszewki, Man Chest

8 Patient Voice

9 Table Introduction and Roles Dr. Gordon Hoag

10 10  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 Table Discussion

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 16 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 Outline

17 17 Heart Failure in BC Ministry Data 2010

18 18 Prevalence of Heart Failure Patients in Millions Year 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

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

20 20 HF Readmissions Lee DS et al. Can J Cardiol 2004;20(6):

21 21 Survival After Admission to Hospital for Heart Failure in BC % survival at 30 months Months Percentage Alive

22 22 Heart Failure is a Malignant Disease Breast Ca (adjuvant tamoxifen) Months Percentage Surviving Cleland and MacFadyen, 2002 SOLVD treatment (on enalapril) Metastatic Prostate Ca Lung Ca

23 23  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 Heart Failure Stats

24 24

25 25 TherapyAgentReduction in 1° Endpoint Self Management23% PharmacologicalACE-I8% - 26% Beta Blocker23% - 65% Spironolactone35% ARB15% DeviceICD23% - 31% CRT24% - 36% Heart Failure Therapies

26 26 Evidence Based HF Therapies in BC

27 27  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 The Care Gap

28 28  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 HF Shared Care

29 29  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 Highlights

30 30  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 Consistent Care Model

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

32 32  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 Dynamic Adjustment

33 33  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 Decision Points & Pathways

34 34  Self-Managed  Patient Education  Patient Action  GP Managed  Pathway  Information Exchange  HF Clinic  Multi-disciplinary Clinic Visit  Specialist Input  Cardiologist Input  Cardiologist Consult Care Management Models

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 36  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 Background

37 37 Cardiologists/Internists Guideline driven care Provincial Hub: Acute HF Program SPH VIHA RJH HFCs CDMs Intern ists IHNs Spec GPs Interior KGH HFCs CDMs Intern ists IHNs Spec GPs Northern PGH HFCs CDMs Intern ists IHNs Spec GPs Regional Centres Additional Diagnostics Specialist Services Medication titration Research Specialist GPs Special training in HF Management Up to date with guidelines CDMs 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 Guideline driven care VCH SPH HFCs CDMs Cardiologists/ Internists IHNs Spec GPs VCH VGH Fraser RCH HFCs CDMs Intern ists IHNs Spec GPs Fraser Surrey Acute HF services Clinical support Guideline Development Education

38 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 39 BC’s Heart Failure Website

40 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 41  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.) Overarching Philosophy will guide the creation of all patient education material

42 42 Indications for Referral to a HFC Heart Function Clinic Referral Form Referral Resources

43 43 Patient History/Assessment Heart Failure Patient Questionnaire

44 44 Patient Assessment Form A Guide to HF Patient Assessment

45 45 Snap shot of patient visit

46 46 Heart Failure 101 Patient Education Resources

47 47 Heart Zones Patient Education Resources

48 48 Daily weight Patient Education Resources

49 49 Sodium Restriction Patient Education Resources

50 50 Fluid Restriction Patient Education Resources

51 51 Activity Patient Education Resources

52 52 Heart Failure Patient E-Learning Module

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

54 54 Funded Sites Sites Under Development Partners in Care – FP / SP Attachment or Referral Project

55 Heart Failure Putting it all Together

56 56

57 57

58 58

59 59 Workflow

60 60 Workflow and Stepped Care

61 61 Stepped Care

62 62

63 63

64 64

65 Table Discussions

66 66  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? Table Discussions

67 Lunch


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