Mariella Martini Coordinator of HPH Emilia Romagna Regional Network

1. Health Promoting Hospitals PATHWAYS OF INTEGRATED CARE FOR PATIENTS AFFECTED BY HEART FAILURE Mariella Martini Coordinator of HPH Emilia Romagna Regional Network

2. The CCM: Chronic Care Model (Ed Wagner, MacColl Institute for Healthcare Innovation) Health System (Health Care Organization) Community Resources and Policies Self-Management Support Decision Support Delivery System Design Clinical Information Systems Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions • TARGET: PATIENTS WITH • NEOPLASTIC PATHOLOGIES • RESPIRATORY FAILURE • CARDIAC DECOMPENSATION Improved Outcomes

3. PATIENT PATH • … as a method for: • systematising ideas and actions • (finding a way out of the confusion “caused • by complexity”, of the routine chaos) • identifying measurable spaces of • efficiency (EBM) and effectiveness, • (translating the evidence into “practices”: • GOOD PERFORMANCE) • - highlighting the “global” needs of the • patient-person • - assigning indicators for monitoring EFFECTIVENESS AND APPROPRIATENESS: Decisions based on scientific evidence (EBM-based decisions) THE PATIENT-PERSON: Decisions based on weighted judgements (Illness Histories) Narrative-based Medicine Evidence-based Medicine

4. DECOMPENSATED PATIENT PATH * Is the diagnosis always informed? * To whom? * How and when? * Which family member is informed of the diagnosis? * Appropriate verbal (and other) language? * ………………………… (PATIENT) PERSON PRESENCE OF THE PROBLEM * Am I the right professional figure? * Am I aware of my state of mind? * Do I possess the right resources to manage my emotions in this relationship? * ……………. OPERATOR IN-DEPTH DIAGNOSTICS * What is the structure and what are the internal relationships of the family? * Who is the reference figure within the family? * ……………. FAMILY COMMUNICATION P P P P P P P P DEFINITION OF PERSONALISED PROGRAMME. SHARED (agreed) THERAPY PROGRAMME. PALLIATIVE TREATMENT INTERACTIVE TREATMENT Define the evaluation specification (product standards) ………………………… INTERACTIVE MONITORING ………………….

5. CURING THE DISEASE EBM-OUTCOME CURING THE SYSTEM ORGANIZATION-OUTCOME PATIENT-OUTCOME CURING THE ILLNESS A S S I S T A N C E P A T H as a useful model for considering not only clinical improvement but all other dimensions as well

6. Aims of the project • To improve the organisation and quality of life of the patientswith a more effective and efficient integrated pathology management, preventing unnecessary hospitalisation or reducing the length of stay • To guarantee patient centrality (empowerment) • To improve the appropriateness of the interventionscentering them on the results, in terms of improved clinical effectiveness but also closer response to patient needs (not only E.B.M. but also patient life histories)

7. Working methodology Phase 1: analysis and development of diagnostic-therapeutic guidelines and organisational-relational protocols/recommendations Phase 2: preparation of theoretical path Phase 3: training programmes for all professionals in the network dealing with Cardiac Decompensation Phase 4: start of experimentation Phase 5: clinical audit to monitor the indicators

8. Working tools/1 • Diagnostic-therapeutic guidelines and organisational-relational recommendations • Path flow-chart • Follow upsheet

9. NYHA 3^ NYHA 3^ NYHA 4^ NYHA 3^ NYHA 4^ NYHA 4^ NYHA 4^ NYHA 3^ NYHA 3^ NYHA 4^ Decompensated patient path PRESENCE OF SYMPTOMS 1ST DIAGNOSIS GENERAL PRACTITIONER HOSPITAL REFERRAL TO LOCAL / HOSPTIAL SPECIALIST FOR FURTHER INVESTIGATIONS INVESTIGATIONS DECOMPENSATION NO YES NYHA I CLASS NYHA II CLASS NYHA III CLASS NYHA IV CLASS

10. Example NYHA 1 GP and specialists communicate by phone and internet SENT TO GENERAL PRACTITIONER WITH DISCHARGE LETTER / SPECIALIST REPORT, COMPLETION OF DECOMPENSATION SHEET AND INDICATION OF PROPOSED THERAPIES AND FOLLOW UP GENERAL PRACTITIONER COMMUNICATES DIAGNOSIS (or repeats the information given by the hospital/territorial doctor) AND EDUCATES THE PATIENT IN TERMS OF CORRECT LIFESTYLE, THE IMPORTANCE OF FOLLOWING THE THERAPY, AND THE RECOGNITION OF SYMPTOMS GP SETS THE THERAPY AND FOLLOW UP (sets the next stage at each check up and notes it on the follow up sheet) STABLE PATIENT EARLY FOLLOW-UP NO YES STAYS IN CLASS I SPECIALIST REPORT INDICATING ANY MODIFICATION IN THE THERAPY AND FOLLOW UP GENERAL PRACTITIONER COMMUNICATES OUTCOME TO PATIENT AND ESTABLISHES THERAPY AND FOLLOW-UP POSSIBLE ADJUSTMENT OF PHARMACOLOGICAL THERAPY SPECIALIST CONSULT

11. Working tools/2 • Self-monitoring sheets paziente: • Weight control sheet • -Blood pressure control sheet • -Physical activity monitoring sheet • -Pharmacological compliance monitoring sheet • Information booklet:given to patient at the time of diagnosis; strong educational impact, with little technical information • Recipe book:given to patient at the time of diagnosis. Includes recipes suited to the whole family

12. Making a “therapy deal” with the patient involves: • correct communication • education of patient and family • control of the adherence to the pharmacological and other types of therapy

13. Communicating the diagnosis • Transferring clear, appropriate messages to the patient concerning his pathology and checking his level of understanding • With the patient’s consent, transferring the same messages to her/his relatives and checking the level of understanding • Not having inattentive, distracted or didactic attitudes • Paying attention to the patient’s doubts, uncertainties and fears • Understanding and managing any attitudes of resentment the patient may have towards us IT IS FUNDAMENTAL FOR ALL THE INVOLVED PROFESSIONALS TO USE THE SAME LANGUAGE

14. Educating the patient/relatives • Initial education at the time of diagnosis (by GP or hospital doctor), with patient/relative training aimed at self-monitoring • Handing over information booklet • Handing over the recipe book • Continuous education by all the professionals involved in the path • Yearly meetings with experts (diet, physical fitness, psychological reactions to the illness and management of such reactions…)

15. Checking pharmacological compliance…. • Ask the patient if he has taken the prescribed medicines • Ask the relatives the same thing • Check the self-monitoring compliance sheet • Objectively assess the consumption of medicines • Check the expected effects of some pharmacological therapies • Investigate the low tolerance of particular medicines

16. Checking non-pharmacological compliance means…. • Checking the introduction • Checking the diuresis • Checking the diet in relation to any cardiovascular risk factors • Checking life style

17. Hospital Case Management Territory GROUP VISIT, FOLLOW-UP PHONE CALL SELF MANAGEMENT Active Follow-up USEFUL TOOLS FOR MANAGING CHRONIC PATIENTS

18. IN GOD WE TRUST. ALL OTHERS MUST USE DATA. W.E. Deming

19. WHERE, WHAT, WHEN, HOW… TO EVALUATE? RESULT PROCESS A SYSTEM OF INDICATORS ...

20. PROCESS RESULT • opening of educational clinics managed by nurses • number of patients following the path • use of tools • home access by cardiologist • reduction in hospitalisation • increase in the amount of Integrated Home Care • illness histories INDICATORS

21. Declare Accountability Document Do Verify