COLLABORATIVE CARE MODELS IN HEART FAILURE

19-05-21 1 COLLABORATIVE CARE MODELS IN HEART FAILURE Harriette Van Spall MD MPH FRCPC Associate Professor of Medicine Division of Cardiology, McMaster University Scientist, Population Health Research Institute Shelley Zieroth MD FRCPC FCCS Associate Professor of Cardiology Section of Cardiology University of Manitoba Disclosures Van Spall • Grants / research funding • Canadian Institutes of Health Research • Ontario’s Ministry of Health and Long Term Care • Center of Healthcare Optimization and Research Delivery • Hamilton Health Sciences Foundation • In-kind research support • Roche Diagnostics 19-05-21 2 Disclosures Zieroth Consulting/Advisory Board: Akcea, Astra Zeneca, Amgen, Alnylam, Bayer, Boehringer Ingelheim, Cardiol Therapeutics, Novartis, Pfizer, Servier Speaker: Boehringer Ingelheim, Novartis, Servier Clinical Trials: Amgen, Astra Zeneca, Bayer, Boehringer Ingelheim, Merck, Novartis Research Grants: Novartis Educational Grants: Servier Objectives 1. Review established healthcare models for the shared care of patients with HF 2. Examine innovative strategies, including technology, for transitional care of patients with HF 3. Discuss approaches for timely access to consultative services from specialists 4. Review tools for knowledge translation 19-05-21 3 I. Review established healthcare models for the shared care of patients with HF TRIPLE AIM vs QUADRUPLE AIM The primary Triple Aim goal is to improve the health of the population, with 2 secondary goals – • improving patient experience and • reducing costs Quadruple Aim adds in • improving the work life of health care clinicians and staff Bodenheimer, Sinsky. Ann Fam Med 2014;12:573-576. 19-05-21 4 Primary Care Volume of HF Visits and Rural vs Urban Gaps Urban patients have more access to specialist care In Canada……..Lack of referral to HF Specialists? And Risk : Treatment Mismatch Based on a cohort study conducted in Ontario in patients alive after an HF hospitalization, approximately 10% of patients with HF were seen at specialized HF clinics after hospital discharge1 HF clinic Outpatient clinic 1. Wijeysundera H, et al. Circ Heart Fail. 2013;6:68-75 2. Howlett J. Specialist heart failure clinics must evolve to stay relevant. Can J Cardiol 2014;30:276-80. 19-05-21 5 Why You Still Need HF Clinics Ezekowitz, JA., et al. Impact of specialist follow-up in outpatients with congestive heart failure. CMAJ. 2005; 172(2): 189-194 Kaplan–Meier survival curves for care received, by ambulatory specialty. Blue line = combined care (both specialist and family physician), Red line = care by family physician only, Black line = no cardiovascular claims (i.e., no physician visits for a cardiovascular cause). The EXPANDED CHRONIC CARE MODEL 19-05-21 6 CONTINUUM OF HF CARE HUB AND SPOKE MODEL Huitema AA, Harkness K, Heckman GA and McKelvie RS. The Spoke-Hub-and-Node Model of Integrated Heart Failure Care. Can J Cardiol. 2018;34:863-870 Quaternary Node Advanced HF Transplant Centre Community Hub HF Centre Ter:ary Hub HF Centre Ter:ary Hub HF Centre Community Hub HF Centre Community Hub HF Centre Local GIM Cardiology CDM Clinic Local GIM Cardiology CDM Clinic Local GIM Cardiology CDM Clinic Local GIM Cardiology CDM Clinic Primary Care Primary Care Primary Care Primary Care Increasing pa:ent complexity and risk 19-05-21 7 Audience Question • Does your HF clinic have a shared care policy with primary care or other specialists? • What’s working? • What’s not working? II. Strategies for shared care: transitions and community-based care 19-05-21 8 Transitional Care Services: a systematic review and network meta-analysis Van Spall et al. Eur J Heart Fail 2017; 19(11):1427-1443. Transitional Care Services: a systematic review and network meta-analysis Van Spall et al. Eur J Heart Fail 2017; 19(11):1427-1443. 19-05-21 9 Transitional Care Services: a systematic review and network meta-analysis Van Spall et al. Eur J Heart Fail 2017; 19(11):1427-1443. Van Spall et al. JAMA 2019; 321(8):753-761. 3-month composite all-cause death, readmission, or ED visit 19-05-21 10 Van Spall et al. JAMA 2019; 321(8):753-761. PACT-HF stepped wedge cluster RCT 30-day composite readmission or ED visit Van Spall et al. JAMA 2019; 321(8):753-761. PACT-HF stepped wedge cluster RCT 19-05-21 11 Remote monitoring & clinical outcomes Bashi et al. J med internet research. 2017; 19(1): e18. Remote monitoring & clinical outcomes Bashi et al. J med internet research. 2017; 19(1): e18. 19-05-21 12 Remote Telemonitoring Koehler et al. Int J Cardiol 2012; 161(3): 143-150. Koehler et al. The Lancet 2018; 392(10152): 1047-1057. Remote Telemedical Management: TIM-HF2 19-05-21 13 Electronic Heart Diary Arulnathan et al. Studies in health tech and inform. 2019; 259: 113-116. Digital innovations and wearable technologies Michard. J Clin Monit Comput 2017; 31:253-259. 19-05-21 14 Wearable technology: Simband smartwatch Nemati et al. Conf Proc IEEE Eng Med Biol Soc 2016; 3394-3397. Smartphone mechanocardiography Lahdenoja et al. IEEE J Biomed Health Inform 2018; 22: 108-118. 19-05-21 15 Barriers • Interoperability between devices and EMRs • Integration with health care providers • Billing for services related to monitoring • Cost Audience Question • What technology does your HF clinic use to enhance • patient self monitoring / care • shared care with primary care providers? • Have they been successful? • What have been the major barriers?....Be honest 19-05-21 16 III. Approaches for timely consultative services between primary care and specialists Integrated Care: Spoke-Hub-and-Node Huitema et al. Canadian Journal of Cardiology 2018;34(7): 863-870. 19-05-21 17 E-Consults in Cardiology Bauer et al. J telemedicine and telecare 2019; 1357633. Telemedicine Technology in Ontario Thompson. Ivey International Centre for Health Innovation (Blog) 2018; 1. 19-05-21 18 OTNconnect App Ontario Telemedicine Network © 2019. Audience Question • Do you see telemedicine consults as a user friendly solution to improved shared care models? • Will this technology be incorporated in your clinic? 19-05-21 19 IV. Tools and resources for primary care provider: knowledge dissemination Knowledge to Action Framework Matthew Menear, Kelly Grindrod, Kathleen Clouston, Peter Norton and France Légaré Canadian Family Physician June 2012, 58 (6) 623-627, reprinted from Graham et al 19-05-21 20 LOCAL KT INITIATIVES • Discharge summaries with specific instructions on uptitration of GDMT embedded in care map Quadruple Aim • Providing all of our uptitration protocols (“HFC in a box”) to all care provider teams in MB 2017 Quadruple Aim • Providing additional CME to primary care regarding triple therapy, device referrals and new agents, Guideline updates - ongoing Quadruple Aim • Enhancing community patient education opportunities with primary care Sept 2018 Triple and Quadruple Aim • Proving telehealth links to twice monthly education heart failure education sessions province wide and to Nursing Stations. Triple and Quadruple Aim • “Pop up” HF clinics, hands on exposure to GDMT and newer therapies Dec 2018 Triple and Quadruple Aim Heartfailure.ca The heartfailure playbook 19-05-21 21 NATIONAL KT INITIATIVES (CCS AND CHFS) https://www.ccs.ca/en/guidelines/heart-failure-program Audience Question • In your opinion what tools have been most successful in the adoption of GDMT among primary care providers? • Locally? • Nationally? • Where can be done better? • Are patients and nurses included in the KT cycle? 19-05-21 22 Thank you for your participation