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

1. 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)

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. Ideas have broad evidence of achieving aim PSP Shared Care COPD Ideas with some evidence of achievingaim LS2 AP LS1 Expert Meeting Ideas perceived as new Develop Ideas Implement and Spread Ideas Test Ideas Strategy for change PSP Prototyping Process and Timelines LS3 LS2 Ideas for change AP AP LS1 Expert Meeting PSP Shared Care HF/COPD Mar’11 May ’12 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 2012. 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.

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

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 0 0 6 12 18 24 30 36 42 48 54 60 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

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. CDMs • Care of pts with chronic diseases • Staff able to provide guideline based care Primary Care Spec GPs Spec GPs Intern ists CDMs CDMs VIHA RJH Spec GPs Cardiologists/ Internists Intern ists Fraser RCH • Regional Centres • Additional Diagnostics • Specialist Services • Medication titration • Research Fraser Surrey IHNs HFCs VCH SPH Spec GPs CDMs VCH VGH HFCs Patient Intern ists CDMs Interior KGH IHNs IHNs Provincial Hub: Acute HF Program SPH IHNs HFCs HFCs Spec GPs Intern ists CDMs Acute HF services Clinical support Guideline Development Education Northern PGH • Specialist GPs • Special training in HF Management • Up to date with guidelines IHNs HFCs • Heart Function Clinics • Cardiologist with dedicated staff • Guideline driven care • IHNs/ICCs • Group practices with specialized training • Guideline driven care Cardiologists/Internists Guideline driven care

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 www.bcheartfailure.ca

40. 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 Practice Resources for HF PSP

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 Indications for Referral to a HFC Heart Function Clinic Referral Form

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