ENSURINGTIMELYOPTIMIZATIONIN HEART FAILURE CARE: A SYSTEMSAPPROACHRobert S McKelvie MD PhD FRCPCWestern University and St. Joseph’s Health CareLondon CanadaMay 10, 2019

ENSURINGTIMELYOPTIMIZATIONIN HEART FAILURE CARE: A SYSTEMSAPPROACHRobert S McKelvie MD PhD FRCPCWestern University and St. Joseph’s Health CareLondon CanadaMay 10, 2019 Conflicts of Interest•No disclosures 2 https://www.cihi.ca/en/hospital-stays-in-canada Accessed May 1, 2019 Heart Failure-a National Problem Burden of heart failure in OntarioPopulation Ontario age 40+ years 7,206,368Approximately 280,000people living with HF. Incidence: 5 per 1000 in age 40+ years (about 38,000new cases a year) Prevalence: 39 per 1000 in age 40+ years1 month mortality from diagnosis: 8%; 1 year mortality from diagnosis: 22.7% 30-day readmission following hospitalization: 9% (heart failure); 21% (all cause)In 2015/16: 65,334 admissions that involved people with HF, 766,681 days in hospitalData source: Discharge Abstract Database (DAD), Heart Failure Cohort (Schultz et al. 2013); National Ambulatory Care Reporting System (NACRS), Ontario Drug Benefit Claims (ODB), Ontario Health Insurance Plan (OHIP) Claims Database, Registered Persons Database(RPDB) Acute Care Utilization in Ontario (FY 2015/16) •83% of people with HF are 65+ years of age•38,000 ER Visits/Year•66,000 hospitalizations/year with a HF diagnosisAverage LOS: 12 days•25,000 hospitalizations/year with a Main Dxof HF Average LOS: 9 days•770,000 days in hospital/yearData source: CIHI DAD/NACRS (FY 2015/16)Note-data represents Ontario residents with valid HCN, age 20+ years using acute care servicesCase: Any diagnostic code is : "I255*" "I500*" "I501*" "I509*" Approximately Therapeutic Approach to Patients with HFrEF Ontario Landscape-Medications 59,3 58,5 10,3 6,1 58,7 58,8 11,2 6,3 58,9 59,3 12,5 6,5010203040506070 ACE/ARB/ARNIBeta BlockerMRATriple therapy Percentage of patients age 65+ years dispensed evidence-based medication at 180 days post heart failure diagnosis in OntarioFY 2015/16 to 2017/18 2015/162016/172017/18 7Data source: Discharge Abstract Database (DAD), Heart Failure Cohort (Schultz et al. 2013); National Ambulatory Care Reporting System (NACRS), Ontario Drug Benefit Claims (ODB), Ontario Health Insurance Plan (OHIP) Claims Database, Registered Persons Database(RPDB) Percent dispensed medication Ontario Landscape-Newer therapy 0,15 0,651,96 2,56 012345678910 90 days post diagnosis180 days post diagnosis Percent of patients age 65+ years dispensed Angiotensin Receptor Blocker/Neprilysn Inhibitor following heart failure diagnosis in OntarioFY 2016/17-2017/18 2016/172017/18 8 Percent dispensed medication Data source: Discharge Abstract Database (DAD), Heart Failure Cohort (Schultz et al. 2013); National Ambulatory Care Reporting System (NACRS), Ontario Drug Benefit Claims (ODB), Ontario Health Insurance Plan (OHIP) Claims Database, Registered Persons Database(RPDB) Ontario Landscape-follow up care 42,536,9 9,8 4,2 36,928,97,8 4,20102030405060708090100 Any physicianFamily MDCardiologistInternist Percent of patients seen by physician within 7 days following hospital discharge for heart failure in OntarioFY 2016/17-2017/18 2016/172017/18 9 Percent seen by physician Data source: Discharge Abstract Database (DAD), Heart Failure Cohort (Schultz et al. 2013); National Ambulatory Care Reporting System (NACRS), Ontario Drug Benefit Claims (ODB), Ontario Health Insurance Plan (OHIP) Claims Database, Registered Persons Database(RPDB) CCS Heart Failure Guideline Recommendations •We recommend that all patients with recurrent HF hospitalizations, irrespective of age, multimorbidity, or frailty, should be referred to a HF disease management program. (Strong Recommendation, High Quality Evidence) •We recommend that care for patients with HF be organized within an integrated system of health care delivery where patient information and care plans are accessible to collaborating practitioners across the continuum of care. (Strong Recommendation, Moderate Quality Evidence)Ezekowitz et al., 2017 Purpose-honorable mentionPurpose-Highlight the systems approach to support better management of patients with HF in OntarioNote-honourable mention that other provinces are exploring system approaches to managing heart failure 11 Building a model for supporting system integration for heart failure care in Ontario Integrated Model of Heart Failure Care: Spoke-Hub-NodeThe intensity and level of care may vary over time with the patient’s complexity and risk changes, but the goal is to ensure that high quality care is available as close to home as possible and that care is coordinated across all levels of care. Goals of Integrated Heart Failure Care Initiative (IHFCI) 14 Understand how providers and teams could improve HF care, with regards to: Improving compliance with clinical best practicesReducing variation in practice and outcomesImproving patient and caregiver experienceProviding evidence-based care close to homeIntegrating care across the continuum Integrating Heart Failure Care Initiative (IHFCI)-Project Objectives In three early adopter sub-regions (London, Ottawa, Guelph)1.Implement CorHealth Ontario’s Spoke-Hub-Node Model of organizing heart failure care2.Implement Health Quality Ontario’s Heart Failure Care in the Community Quality Standard3.Develop a Provincial Roadmap for integrating heart failure care in Ontario based on the lessons learned through the three ‘early adopter’ teams (June 2018-March 2019) Insert your footer here16 1.London and area 2.Guelph/Kitchener area 3.Ottawa region Early Adopter Teams Early Adopter Teams•Each early adopter team: •Clinical and administrative leadership * need representation from spoke, hub and node locations•Regional administrative leadership •Front line providers •Patient/caregivers •CorHealth Ontario-project management support, coaching, provider education, administrative data interpretation, linking stakeholders (“match making”) Dedicated project manager at each site:Field notes, lessons learned, biweekly meetings and reports submitted to CorHealth(deep dive into notes-Evaluative report available electronically)17 Sources of information to inform Roadmap Early Adopter Team Meetings and Activities Project Manager Field Notes and Reports ProvinicialTask Group 18 The Roadmap for Improving Integrated HF Care Learnings from the 3 Early Adopter Teams distilled into 10 recommendations around how to implement integrated, evidence-based HF Care. Phase 1: Getting Started Phase 2: Taking ActionPhase 3:Sustaining, Scaling Up and Spreading Recommendations focus on 4 Critical Considerations Spanning all Phases Patient and Caregiver VoiceCollaborative Leadership Education Data and Reporting Example from Roadmap 20 Example from Roadmap 21 IHFCI Implementation Support Toolkit Summary•Timely optimizing of care for heart failure patients demands a systems approach to organizing care•Integrating care at a systems level requires a paradigm shift in how we currently organize care •Ontario is proposing a spoke-hub-node model of care –early days helped shape the Provincial Roadmap for Integrating HF Care•Documents, tools, resources are available electronically-material will continue to evolve as the initiative continues to growWebsite for tools and resources: www.corhealthontario.ca 23