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Shared System of Care (COPD/HF) Prototype Session 3
Westin Wall Centre
May 7, 2012
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
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
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
5Man, Sin, Ignaszewki, Man 2012
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
“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 2012. Chest
Patient Voice
Table Introduction and Roles
Dr. Gordon Hoag
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
Shared System of Care (COPD): Innovations and Support
Part I
Break
(15 minutes)
Shared System of Care (COPD): Innovations and Support
Part II
Lunch
Heart Failure Shared CareDr. Sean A. Virani
Dr. Bruce Hobson
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
Heart Failure in BC
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Incidence
Prevalence
Mortality
Ministry Data 2010
18
Prevalence of Heart Failure
0
2
4
6
8
10
12
Pat
ient
s in
Mill
ions
4.8
3.5
10.0
Year
1991 2001 2037
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
Projected Annual Incident HF Hospitalizations in Canada
0
20000
40000
60000
80000
100000
120000
140000
160000
1996 2005 2015 2025 2035 2045
ADHF Diagnosis
Year
Num
ber o
f Cas
es
Johansen L et al., Can Journal of Cardiol
20
HF Readmissions
Lee DS et al. Can J Cardiol 2004;20(6):599-607.
21
Survival After Admission to Hospital for Heart Failure in BC
0 5 10 15 20 25 30 35 40 45 50
0
20
40
60
80
100
50% survival at 30 months
Months
Per
cent
age
Aliv
e
http://www.healthservices.gov.bc.ca
22
Heart Failure is a Malignant Disease
0 6 12 18 24 30 36 42 48 54 60
0
20
40
60
80
100
Breast Ca (adjuvant tamoxifen)
Months
Perc
enta
ge S
urvi
ving
Cleland and MacFadyen, 2002
SOLVD treatment (on enalapril)
Metastatic Prostate Ca
Lung Ca
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
$0
$100,000,000
$200,000,000
$300,000,000
$400,000,000
$500,000,000
$600,000,000
2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Hospital
MSP
Pharmacare
Total
24
25
Therapy AgentReduction 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%
Heart Failure Therapies
26
0
10
20
30
40
50
60
70
80
90
100
All Ages Age < 85
ACE/ARB
BB
Evidence Based HF Therapies in BC
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
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
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
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
Risk Factor Management
Underlying Disease Management
Patient Self Management
› Tele-monitoring
Pharmaceutical Treatments
Co-morbid disease management
Interventional Therapies
Topics for Treatment Guidance
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
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
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
Provincial Heart Failure Strategy/ Network
Provincial HUB Team:
Bonnie Catlin: Provincial HF Clinical Nurse Specialist
Andy Ignaszewski: Medical Director
Janis McGladrey: Administrative Director
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
Cardiologists/InternistsGuideline driven care
ProvincialHub:
Acute HF Program
SPH
VIHA
RJH
HFCs
CDMs
Internists
IHNs
Spec
GPs
Inte
rior
KGH HFC
s
CD
Ms
Intern
ists
IHN
s
Spec
GPs
NorthernPGH
HFCs
CDMs
Internists
IHNs
SpecGPs
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
VCHSPH
HFCs
CDMs
Cardiologists/
Internists
IHNs
SpecGPs
VCHVGH
Fraser
RCH
HFCs
CDMs
Internists
IHNs
Spec
GPs
Fraser
Surrey
Acute HF servicesClinical supportGuideline DevelopmentEducation
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
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
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
Indications for Referral to a HFC Heart Function Clinic Referral Form
Referral Resources
43
Patient History/Assessment
Heart Failure
Patient
Questionnaire
44
PatientAssessmentForm
A Guide to HF Patient Assessment
45
Snap shot
of patient
visit
46
Heart Failure 101
Patient Education Resources
47
Heart Zones
Patient Education Resources
48
Daily weight
Patient Education Resources
49
Sodium Restriction
Patient Education Resources
50
Fluid Restriction
Patient Education Resources
51
Activity
Patient Education Resources
52
Heart Failure Patient E-Learning Module
53
Primary Care Physician HF Pathway: 3 options: Step management
Still symptomatic
Start treatment
Guide to caring for your HF patients
54
Funded Sites
Sites Under Development
Partners in Care – FP / SP Attachment or Referral Project
Heart Failure
Putting it allTogether
56
57
58
59
Workflow
60
Workflow and Stepped Care
61
Stepped Care
62
63
64
Table Discussions
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
Lunch
