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) 2

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 3

PSP Prototyping Process and Timelines

Ideas have broad evidence of achieving aim Ideas for change Ideas with some evidence of achieving aim Ideas perceived as new

Expert Meeting

PSP Shared Care COPD

LS1 AP LS2 AP LS3 AP Expert Meeting LS1

PSP Shared Care HF/COPD

LS2

Develop Ideas

Mar’11 May ’12 May’13

Test Ideas Implement and Spread Ideas Strategy for change

4

Man, Sin, Ignaszewki, Man 2012

5

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 6

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 7

Patient Voice

Table Introduction and Roles

Dr. Gordon Hoag

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 10

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 Care

Dr. Sean A. Virani Dr. Bruce Hobson

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 16

Heart Failure in BC

100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 Incidence Prevalence Mortality

Ministry Data 2010 17

Prevalence of Heart Failure 12 10 8 0 2 4 6 3.5

1991 4.8

10.0

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 2001 Year 2037 18

Projected Annual Incident HF Hospitalizations in Canada 160000 140000 120000 100000 80000 60000 40000 20000 0 ADHF Diagnosis 1996 2005 2015 Year 2025 2035 2045 Johansen L et al., Can Journal of Cardiol 19

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

20

Survival After Admission to Hospital for Heart Failure in BC 100 80 60 40 50% survival at 30 months 20 0 0 5 10 15 20 25 30 35 40 45 50 Months http://www.healthservices.gov.bc.ca

21

Heart Failure is a Malignant Disease 100 80 60 40 Breast Ca (adjuvant tamoxifen) 20 0 0 6 12 18 24 30 36 42 48 54 60 Cleland and MacFadyen, 2002 Months SOLVD treatment (on enalapril) Metastatic Prostate Ca Lung Ca 22

Heart Failure Stats

$600,000,000



$500,000,000

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

$400,000,000 $300,000,000 $200,000,000 $100,000,000 $0 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 Hospital MSP Pharmacare Total

 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 23

24

Heart Failure Therapies

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

Evidence Based HF Therapies in BC

100 90 80 70 60 50 40 30 20 10 0 All Ages Age < 85 ACE/ARB BB

26

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 27

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 28

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 29

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 30

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

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 32

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 33

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 34

Provincial Heart Failure Strategy/ Network

Provincial HUB Team: Bonnie Catlin: Provincial HF Clinical Nurse Specialist Andy Ignaszewski: Medical Director Janis McGladrey: Administrative Director

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 36

CDMs •Care of pts with chronic diseases •Staff able to provide guideline based care Cardiologists/Internists Guideline driven care IHNs/ICCs •Group practices with specialized training •Guideline driven care Regional Centres •

Additional Diagnostics

•

Specialist Services

•

Medication titration

•

Research

Provincial Hub: Acute HF Program SPH Acute HF services Clinical support Guideline Development Education Heart Function Clinics •Cardiologist with dedicated staff •Guideline driven care Specialist GPs •Special training in HF Management •Up to date with guidelines 37

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 38

BC’s Heart Failure Website www.bcheartfailure.ca

39

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 40

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.) 41

Referral Resources

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

Patient History/Assessment

Heart Failure Patient Questionnaire 43

A Guide to HF Patient Assessment

Patient Assessment Form 44

Snap shot of patient visit

45

Patient Education Resources Heart Failure 101

46

Patient Education Resources Heart Zones

47

Patient Education Resources Daily weight

48

Patient Education Resources Sodium Restriction

49

Patient Education Resources Fluid Restriction

50

Patient Education Resources Activity

51

Heart Failure Patient E-Learning Module 52

Guide to caring for your HF patients

Primary Care Physician HF Pathway: 3 options: Step management Still symptomatic Start treatment

53

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

Heart Failure Putting it all Together

56

57

58

Workflow 59

Workflow and Stepped Care 60

Stepped Care 61

62

63

64

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?

66

Lunch