Transcript Document
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
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Man, Sin, Ignaszewki, Man 2012
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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.
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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
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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
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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
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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
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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
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Patient Education Resources Heart Failure 101
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Patient Education Resources Heart Zones
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Patient Education Resources Daily weight
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Patient Education Resources Sodium Restriction
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Patient Education Resources Fluid Restriction
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Patient Education Resources Activity
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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
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Partners in Care – FP / SP Attachment or Referral Project Funded Sites Sites Under Development 54
Heart Failure Putting it all Together
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57
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Workflow 59
Workflow and Stepped Care 60
Stepped Care 61
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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?
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