Heart Function Clinics by Annemarie Kaan MCN RN CCN(C) CCTN
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1. Heart function clinics (HFCs) provide multidisciplinary care for heart failure patients using specialists like cardiologists, nurses, pharmacists, and dietitians. 2. Guidelines recommend HFCs for higher-risk patients to improve outcomes through education, adherence support, and close follow-up. 3. A "hub and spoke" model is proposed to connect HFCs across British Columbia through regional centers and support primary care in local communities using telehealth and innovative models.
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Heart Function Clinics by Annemarie Kaan MCN RN CCN(C) CCTN
- 1. Heart Function Clinics Annemarie Kaan MCN RN CCN(C) CCTN Clinical Nurse Specialist Heart Failure and Transplantation St Paul’s Hospital, Vancouver
- 2. Outline • History • What do HFCs do? • What do the guidelines say? • Patient teaching/coaching • BC Heart Failure Network • Referring • The future
- 3. History • Multidisciplinary clinics – 1970s and 80s • Edmonton – Mid ’90s • Surrey – Late1990s • St Paul’s HF Clinic – 1999 – It’s FUNCTION, not FAILURE! • VGH – 2008
- 4. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.
- 5. So what exactly do HFCs do? • Provide access to other specialties – ICD/PM – CRT – TAVI – Surgery – Palliative care • Multidisciplinary team
- 6. 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.
- 7. Which HCPs are essential members of any HF MDT? Patients and their families should be fully involved in making decisions throughout the care pathway Patients and their families should be fully involved in making decisions throughout the care pathway The key teamThe key team Cardiologist/ internistCardiologist/ internist Specialist Nursing team: RNs Advanced Practice (NP/CNS) Specialist Nursing team: RNs Advanced Practice (NP/CNS) Primary CarePrimary Care Patient-dependent specialistsPatient-dependent specialists PharmacistPharmacist DietitianDietitian GeriatricianGeriatrician PhysiotherapistPhysiotherapist Psychosocial team Psychosocial team Other specialists Other specialists Palliative care remains an option throughout the care pathway in HF and not only for patients at the end of their lives
- 8. 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.
- 9. 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.
- 10. 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.
- 11. Patient Teaching
- 15. 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
- 26. Heart Failure Think Tank 2009 • Provincial Advisory Panel for Cardiac Health – Think tank – Recommendations
- 27. 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
- 28. 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
- 29. Cardiologists/Internists Guideline driven care Provincial Hub: Acute HF Program SPH VIHA RJH HFCs CDMs Intern ists IHNs Spec GPs Interior KGH HFCs CDMs Intern ists IHNs SpecGPs NorthernPGH HFCs CDMs Intern ists 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 VCH SPH HFCs CDMs Cardiologists/ Internists IHNs SpecGPs VCH VGH Fraser RCH HFCs CDMs Intern ists IHNs Spec GPs Fraser Surrey Acute HF services Clinical support Guideline Development Education
- 32. Referring
- 37. • No show rate 10% or more in VGH and St Paul’s – Why? * Inadequate information * Socio-economic * Cultural * Distance * Multiple comorbidities * Mobility/age
- 38. Where should I refer? – tips 1. Potential transplant candidate? • Age, other options, comorbidities → St Paul’s (consult and follow up plan) 1. Do they need high level HF care? • ICD, CRT other devices → Regional hub 1. Age/mobility/distance/personal preference? → Local HFC
- 39. The future… • Care in the home • Centralized triage – One referral number • Increased partnership with primary care • Partnerships with other chronic disease programs
- 40. 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
Editor's Notes
- Optimizing length of hospitalization: Although increased length of stay can result from inappropriate care, it has been found that patients who receive specialist input have longer lengths of stay than those who do not, as HF specialists appear to be more rigorous in ensuring that patients receive optimal care and are stable before discharge.1 Increasing access to cardiac rehabilitation: Please note that in some regions and countries, cardiac rehabilitation is not necessarily available to HF patients, therefore access might not be made possible despite an MDT approach. It should also be noted that the most trials on MDT management tend to be conducted after acute hospitalizations. References: 1. National Heart Failure Audit, April 2012-March 2013. Available from: www.bsh.org.uk/resources/national-heart-failure-audit/. Accessed March 2016.
- The aim of this slide is to highlight the minimum requirements for an effective MDT (as supported by a systematic review by McAlister et al.) The CF should start by asking the participants to suggest which members of the MDT make up the key team and which should be considered as patient-dependent specialists After approximately 5 minutes, the CF should click through to reveal the list of team members who are recommended to represent a minimal requirement for an effective MDT The CF should take care to highlight the following points when presenting this: The MDT may include an ‘infinite’ number of additional specialties and ultimately their inclusion should be based on the unique needs of each specific patient Inclusions in the key team are supported by data from a systematic review of MDT working by McAlister et al., which found that including a HF nurse and ready access to a clinician who specialises in HF is crucial to the success of an MDT program; a PCP and PC nurse were also included in this core team since many patients are transitioned to primary care and will be managed in that setting Not all regions will have the same kind of access to these team members so the CF should highlight that these minimum requirements represent an optimal situation