heart function clinics by annemarie kaan mcn rn ccn(c) cctn
TRANSCRIPT
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Heart Function ClinicsAnnemarie Kaan MCN RN CCN(C) CCTN
Clinical Nurse Specialist
Heart Failure and Transplantation
St Paul’s Hospital, Vancouver
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Outline
• History• What do HFCs do?• What do the guidelines say?• Patient teaching/coaching• BC Heart Failure Network• Referring• The future
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History• Multidisciplinary clinics
– 1970s and 80s• Edmonton
– Mid ’90s• Surrey
– Late1990s• St Paul’s HF Clinic
– 1999– It’s FUNCTION, not FAILURE!
• VGH– 2008
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Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.
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So what exactly do HFCs do?
• Provide access to other specialties– ICD/PM– CRT– TAVI– Surgery– Palliative care
• Multidisciplinary team
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The benefits of MDT working
An MDT approach may improve patient outcomes by: – reducing mortality1 and morbidity
– reducing length of hospitalization1
– curtailing hospital readmission1
– improving adherence to medication and dietary advice1–3
– reducing healthcare costs1
– improving symptom recognition
– increasing access to cardiac rehabilitation.
1. Frankenstein L, et al. Rev Esp Cardiol. 2015; 68(10):885–891. 2. Smith CE, et al. Circ Heart Fail. 2014; 7:888–894. 3. Kasper EK, et al. J Am Coll Cardiol. 2002; 39:471–480.
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Which HCPs are essential members of any HF MDT?
Patients and their families should be fully involved in making decisions throughout the care pathway
The key team
Cardiologist/ internistSpecialist Nursing team:
RNsAdvanced Practice (NP/CNS)
Primary Care
Patient-dependent specialists
Pharmacist Dietitian Geriatrician Physiotherapist Psychosocial team
Other specialists
Palliative care remains an option throughout the care pathway in HF and not only for patients at the end of their lives
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Disease Management Programs• Recommendations
– Specialized hospital-based clinics or DMPs staffed by physicians, nurses, pharmacists, dietitians and other health care professionals with expertise in HF management should be developed and used for assessment and management of higher-risk (eg, two or more HF admissions in six months) HF patients
(Class I, Level A)
– Multidisciplinary care should include close follow-up, and patient and caregiver education in an outpatient HF clinic and/or through telemanagement or telemonitoring, or home visits by specialized HF health care professionals where resources are available
(Class I, Level A)
Howlett JG, McKelvie RS, Costigan J et al. Can J Cardiol 2010;26(4):185-202.
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Disease Management Programs
• Recommendations (cont’d)– Patients with recurrent HF hospitalization
should be referred to a DMP by family physicians, emergency room physicians, internists or cardiologists for follow-up within four weeks of hospital or emergency department discharge, or sooner where feasible
(Class I, Level A)
Howlett JG, McKelvie RS, Costigan J et al. Can J Cardiol 2010;26(4):185-202.
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Disease Management Programs• Practical Tips
– The optimal care model should reflect local circumstances, current resources and available health care personnel. In some situations, it may be beneficial to include HF care in an integrated model of care with other chronic diseases such as diabetes mellitus, which is related to the development of cardiovascular disease
– Integration of a DMP into a primary care setting, with adequate specialist support may be the most feasible solution in certain health care settings
– Practical resources to aid in HF diagnosis and management should be made available across the continuum of community health care delivery
Howlett JG, McKelvie RS, Costigan J et al. Can J Cardiol 2010;26(4):185-202.
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Patient Teaching
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Tips
• Use plain language• Limit information to 2 or 3 key points• Be specific and concrete• Demonstrate, draw pictures, use models• Repeat and summarize• Open ended questions• Teach back
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https://www.fin.gc.ca/pub/eficap-rebvpc/report-rapport-eng.asp
Gov’t Canada website – June 2016
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Heart Failure Think Tank 2009
• Provincial Advisory Panel for Cardiac Health– Think tank– Recommendations
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Gaps in care
• Only a few Heart Failure Clinics• Inability to provide care to entire province• Less than 5% patients referred to a specialist clinic
– Most cared for by GPs/Internists
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Recommendations• “Hub and Spoke” model of HFC• Connect rural and remote areas• Develop tools
– Inpatients – transition to home– Outpatients
• Keep patients in their communities– Telehealth– Innovative models– Support primary care
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Cardiologists/InternistsGuideline driven care
ProvincialHub:
Acute HF Program
SPH
VIHARJH
HFCs
CDMs
Internists
IHNs
SpecGPs
Inter
iorKG
H HFCs
CD
Ms
Intern
ists
IHNs
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
SpecGPs
Fraser
Surrey
Acute HF servicesClinical supportGuideline DevelopmentEducation
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Referring
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• No show rate 10% or more in VGH and St Paul’s– Why?
* Inadequate information
* Socio-economic
* Cultural
* Distance
* Multiple comorbidities
* Mobility/age
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Where should I refer? – tips
1. Potential transplant candidate?• Age, other options, comorbidities St Paul’s (consult and follow up plan)
2. Do they need high level HF care?• ICD, CRT other devices Regional hub
3. Age/mobility/distance/personal preference? Local HFC
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The future…
• Care in the home• Centralized triage
– One referral number
• Increased partnership with primary care• Partnerships with other chronic disease programs
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To summarize
• HFCs have evolved and expanded in the last 20 years
• Multidisciplinary model improves lives• Certain populations still underserviced• The future lies in bringing the HF clinic to the
patient
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