TABLE 1: HEART FAILURE EXPERT TASK GROUP
Name
Heather Sherrard, co-chair
Dr. Lisa Mielniczuk, co-chair
Title & Organization
Vice President, Clinical Services, University of Ottawa Heart Institute
Kim Peterson
Eleanor Wright
Susan Coulas
Arlene Thomson
Sheila Bauer
Dr. Robert Bourrier
Dr. Nahid Azad
Christine Struthers
Dr. John Scott
Dr. Judy Chow
Norvinda Rodger
Assistant Professor of Medicine, University of Ottawa
Division of Cardiology, Heart Failure and Cardiac Transplantation
Co-Medical Director, Pulmonary Hypertension Clinic
Vice President of Client Services, CCAC
Director of Emergency & ICU, Pembroke Regional Hospital
TeleMedicine, CCAC Nursing and Pre-Op Clinic, & Inservice Coordinator &
Pharmacy Nursing Supervisor, St. Francis Memorial Hospital (Barry’s Bay)
Program Director, Cardiovascular Services, Thunder Bay Regional Health
Sciences Centre (Aboriginal Perspective)
Long-Term-Care(LTC) Home Administrator, Peter D. Clark at City of Ottawa
Family Physician, Sandy Hill Community Health Centre
Geriatric Medicine, Professor of Medicine, University of Ottawa
APN Cardiac Telehealth, University of Ottawa Heart Institute
Palliative Care, University of Ottawa Heart Institute & The Ottawa Hospital
Primary Care Physician, Rideau Family Health Team
Network Manager & Senior Planner, Champlain CVD Prevention Network
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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1.0 The Case For Action ............................................................................................................................. 3
2.0 Methodology .......................................................................................................................................... 4
3.0 Environmental Scan .............................................................................................................................. 5
4.0 Summary of Recommended Strategy ................................................................................................. 9
5.0 Performance Management Plan ........................................................................................................ 18
6.0 Leadership and Partner Roles ........................................................................................................... 18
7.0 Prioritization & Resources Requirements ........................................................................................ 19
8.0 Impact ................................................................................................................................................... 20
9.0 Risk Assessment ................................................................................................................................ 21
References ................................................................................................................................................. 22
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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1.0 THE CASE FOR ACTION
1.1 BACKGROUND
More than 500,000 Canadians are affected by heart failure with 50,000 new patients diagnosed each year. The mortality remains staggering, with a five-year age-adjusted rate of 45% 1 . It’s a chronic, progressive disease characterized by frequent hospital admissions, high mortality and morbidity rates, and high consumption of medical resources representing a significant cost burden for our health care system in Canada 2 . In fact, heart failure is the most common cause of hospitalization of people over 65 years of age. And, as with most western countries, the burden of heart failure in Canada is increasing, primarily as a result of improved medical management, improved diagnostics, increased survival among patients with hypertension and coronary artery disease and an aging population that is living longer and becoming more susceptible to heart failure. Heart disease and stroke costs the Canadian economy more than $20.9 billion every year in physician services, hospital costs, lost wages and decreased productivity 3 .
As health care dollars become scarcer and health care delivery moves into an era of heightened accountability, the need for a higher level of integration, coordination, and standardization of quality care has become increasingly evident. Recognizing that a more comprehensive, multi-sector view and collaborative environment is needed for heart failure care in the region, the Champlain Cardiovascular
Disease Prevention Network (CCPN) under the leadership of the University of Ottawa Heart Institute
(UOHI) assembled a multi-sector expert task group with the mandate of developing a regional integrated heart failure strategy. The purpose of this strategy is to integrate and standardize care across sectors and facilitate a more efficient and coordinated system of care with the goal of improving quality of care, reducing emergency visits and avoidable admissions/re-admission and ultimately reducing costs in the health care system.
1.2 STRATEGIC ALIGNMENT
Heart failure is the most common cause of hospitalization of people over 65 years of age. With the incidence and prevalence of heart failure on the rise and prevalence estimated to nearly double due to the aging population by the year 2030, strategies are needed to ensure system efficiency and sustainability. This regional integrated heart failure strategy is strongly aligned with provincial, regional and local priorities of reducing emergency visits and avoidable readmissions.
1.2.1 Provincial Context
As part of the Excellent Care for All Act (ECFAA), the Ministry of Health and Long-term Care (MOHLTC) is pursuing provincial initiatives that contribute to system sustainability by improving quality of care, addressing gaps between evidence and practice and supporting evidence-based care. Reducing avoidable admissions has been identified as an area of provincial priority in the Excellent Care for All
Strategy, where improvements in quality of care for Ontarians are also expected to contribute to the sustainability of the health care system 4 .
Avoidable hospitalizations include hospitalizations which could have been prevented with comprehensive primary care focused on chronic disease management and prevention (for patients with what are sometimes referred to as ambulatory care-sensitive conditions); hospital days due to preventable adverse events in hospital; and, readmissions to hospital which could have been avoided if the care in hospital or the care after discharge was optimized. Avoiding preventable hospitalizations represents better quality of care for patients as well as better value and sustainability for the system. A recent report prepared by an
Avoidable Hospitalization Advisory panel established by MOHLTC recommends that initial efforts to reduce avoidable hospitalizations focus on safe, effective transitions in care to reduce readmissions to
hospital, while building the system’s capacity to increase the area of focus in subsequent years
4 .
Avoidable emergency department (ED) visits continue to be a provincial priority. Although progress has been made, wait times are still too long; falling short of provincial targets. Potential avoidable ED visits are common among long-term care residents. Because of the high-risk nature of heart failure, approximately 80% of ED presentations for presumed heart failure are admitted to the hospital 5 . Early identification and treatment of heart failure in primary care is critical to preventing an avoidable ED visit.
3
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY

1.2.2 Local Context
The proposed strategy is also well aligned with local priorities and initiatives. As part of their 2012-2013
Annual Business plan, the Champlain LHIN identified the reduction of 30-day readmission rates for selected Case Mix Groups (CMG) including heart failure through support of evidence-based programs and primary care engagement.
The UOHI has demonstrated leadership in reducing hospital readmissions through the introduction of innovative, best practice interventions. Two such programs are its Home Telehealth Monitoring program which supervises patients in the comfort of their home through daily remote contact; and, the Champlain
Get with the Guidelines program for ACS and Heart Failure, a quality improvement initiative that ensures patients admitted to hospitals in the region are treated according to evidence-based guidelines. These programs, which have been rolled out to hospitals across the Champlain region, have demonstrated success.
1.2.3 CCPN
The CCPN’s mission is to reduce the burden of cardiovascular disease (CVD) and ensure the residents living in the Champlain region are the most heart healthy and stroke-free in Ontario and Canada. To achieve this, the CCPN is focused on integrated approaches which span the prevention continuum of care and build on its existing assets, infrastructure, and successes to date.
As part of its 2007-2012 Champlain CVD Prevention Strategy, the CCPN, under the leadership of the
UOHI, introduced two evidence-based, best practice programs – the Get with Guidelines initiatives mentioned above, and in partnership with numerous clinical experts, the Champlain Primary Care CVD
Prevention and Management Guideline to provide primary care physicians and health professionals with the latest evidence in preventing and managing CVD risk factor and related diseases such as heart failure.
To facilitate system-level change, it is essential to build strong, trusting relationships among clinical leaders and champions for which the UOHI and CCPN have succeeded in doing so. Both the UOHI and the CCPN are committed to continued excellence and leadership in CVD prevention and management.
2.0 METHODOLOGY
Following consultation with numerous regional and provincial partners and stakeholders, the CCPN identified a regional integrated heart failure strategy as a short-listed priority area of the 2013-2016
Champlain CVD Strategy.
With the leadership of the UOHI, a multi-sector expert task group representing stakeholders from primary care, specialty care, community care and acute care was assembled to develop an integrated heart failure strategy for the region. Please refer to Table I on page 1 for a listing of the membership.
In developing an integrated heart failure strategy, the expert task group followed these steps:
 Step 1: Environmental Scan: (1) Obtained a snapshot of the profile of heart failure in the Champlain region; (2) Identified heart failure specific assets in the region and complementary assets that could be leveraged.
 Step 2: Gap Analysis & Opportunity Identification: (1) Reviewed exemplary models of heart failure care; (2) Performed a gap analysis of existing programs/services and best practices; (3)
Identified needs and prioritized according to greatest opportunity for impact and resource requirements using the three funding scenarios.
 Step 3: Develop Blueprint: Developed recommended strategies including heart failure program components, partnerships & linkages, resource requirements and clearly stated goals and metrics.
The recommended strategies were presented in their draft form to a group of nearly 30 primary care providers from Family Health Teams in the region for their feedback and validation.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY

3.0 ENVIRONMENTAL SCAN
1.3 Profile of Heart Failure in Canada
More than 500,000 Canadians are affected by heart failure with 50,000 new patients diagnosed each year. The mortality remains staggering, with a five-year age-adjusted rate of 45% 6 . Women already constitute the majority of heart failure patients and, given their longer life expectancy, the proportion of elderly women with heart failure is likely to increase further 7 .
Heart Failure Cases on the Rise
Johansen et al. Can J Cardiol 2003;19(4):430-5. [Canadian Heart Failure Network www.chfn.ca]
Number of Hospitalizations for CHF (actual and projected) in Canada 1980-2025
Source: Heart & Stroke Foundation of Canada [Canadian Heart Failure Network www.chfn.ca]
Number of CHF Deaths (actual and projected) in Canada, 1980-2025
Source: Heart & Stroke Foundation of Canada [Canadian Heart Failure Network www.chfn.ca]
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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1.3.1 Profile of Heart Failure in the Champlain Region
The Champlain Region is home to over 1.2 million residents, representing about 10% of the Ontario population. Ottawa is the largest of the planning areas with 882,477 residents, and North Lanark/ North
Grenville the smallest with 47,989 residents 8 .
In the Champlain Region:
 an estimated 12,000 residents are affected by heart failure based on the overall Canadian prevalence of 1% 9 ;
 greater than 1300 discharges from hospital for heart failure occurred in 2010, with an unplanned re-admission rate of 22% within 30 days of discharge (range 11-36%); this was 25-50% greater than expected based on the predicted probability of re-admission 10 ;
 hospitalization rates increase dramatically with age (see table 2); and,
 hospitalization rates per 100,000 are significantly greater in the Renfrew County (205.3) and
Eastern Counties (183.8) as compared to the City of Ottawa (128.1) (see table 3).
TABLE 2. AGE- AND SEX-SPECIFIC HOSPITALIZATION RATES (PER 100,000 POPULATION),
CHAMPLAIN REGION, 2006-2009
Heart Failure
AGE
GROUP
2006 2007
Females
2008 2009 2006 2007
Males
2008 2009
20-49
2.6 3.0 3.7 7.4 9.7 12.0 9.7 11.5
50-64
64.3 64.8 62.0 90.4 125.9 130.0 138.1 128.1
65-74
340.9 352.0 338.5 337.5 548.2 536.9 512.1 455.6
75+
1565.1 1417.0 1352.1 1386.4 1912.7 1698.7 1621.0 1516.0
All Ages
201.2 189.2 182.3 195.4 203.3 195.1 191.8 180.6
It is important to note that heart failure is also an associated cause for many other hospitalizations. On average, in only one-third of hospitalizations where the individual was admitted with heart failure was it identified as the most responsible reason for hospitalization. This underscores that heart failure often presents as the end-stage of other health conditions 11 .
TABLE 3: AGE-STANDARDIZED HOSPITALIZATION RATES (PER 100,000 POPULATION) FOR
CITY OF OTTAWA, EASTERN COUNTIES, AND RENFREW COUNTY, 2006-2009
2006
2007
2008
2009
Heart Failure
City of Ottawa Eastern Counties
131.9 223.5
124.3
121.6
128.1
216.8
206.8
205.3
Renfrew County
218.2
197.3
192.8
183.8
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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1.3.2 Women and Heart Failure
Recognizing gender differences exist, the POWER Study (Project for an Ontario Women's Health
Evidence-Based Report), a multi-year project funded by Echo: Improving Women's Health in Ontario (an agency of MOHLTC), was initiated to produce a comprehensive provincial report on women's health to serve as an evidence-based tool for policy makers, providers, and consumers in their efforts to improve health and reduce health inequities among Ontario women.
The POWER Study examines gender differences on a comprehensive set of evidence-based indicators as well as differences among women associated with socioeconomic status, ethnicity, and geography with an emphasizes on indicators that are modifiable and can support efforts to link measures to intervention and improvement. Despite progress, gender gaps in care persist.
In 2009, a chapter on CVD was released with a section specific to heart failure. According to the Study 12 , there are some differences in the management of patients admitted to hospital for heart failure (HF) by sex. Women were less likely than men to have a cardiologist as their most responsible physician while in hospital and more likely to be under the sole care of a general practitioner/ family physician. This pattern was also seen for outpatient care in newly diagnosed HF patients. Women were less likely than men to undergo evaluation and cardiac testing for heart failure, including left ventricular function evaluation, cardiac stress testing, echocardiography and angiography. These differences were reduced, but not eliminated, with age-adjustment. Regular weight measurement while in hospital is used to assess patients for volume overload. Women were less likely than men to have their weight measured regularly while in hospital. With respect to outcome indicators, women and men had similar rates of non-elective readmissions (within 30 days and within one year of discharge) but had lower rates of emergency department use than men. Crude mortality rates for women and men were similar, but after riskadjustment for age and co-morbidities, women were less likely than men to die within one year. Key findings by sex, in the Champlain LHIN in 2005/06 are as follows:

P ercentage of adults age ≥ 45 with newly diagnosed HF who were seen by a specialist
(cardiologists, internists and/or geriatricians) within one year of initial diagnosis was proportionately lower for women (66%) than men (75%).
 Percentage of adults age ≥ 45 who were under the sole care of a general practitioner/family physician (GP/FP) while hospitalized for HF was greater for women (25%) than men (18%).
 Percentage of HF patients age ≥ 65 who filled a prescription for ACE inhibitor and/or ARB one year post discharge from hospital was proportionately lower for women (63%) than men (65%).
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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1.4 Heart Failure Assets
Not only is the Champlain Region home to Canada's largest and foremost cardiovascular health centre –
University of Ottawa Heart Institute – it is fortunate to have a number of important building blocks/assets in place which are listed in Table 4.
TABLE 4: HEART FAILURE ASSETS IN THE CHAMPLAIN REGION
CATEGORY SERVICE PROVIDER & PROGRAM
Telehealth
Technologies
Evidence-based
Clinical Guidelines
 University of Ottawa Heart Institute Home Telehealth, Telehome Monitoring and Interactive Voice Response (automated calling)
 The Champlain Get with the Guidelines – Heart Failure (and regional discharge planning initiative)
 The Champlain Primary Care CVD Prevention & Management Guideline
Heart Failure Clinics  University of Ottawa Heart Institute Heart Function/Transplantation Clinic
 University of Ottawa Heart Institute Acute Cardiac Referral Clinic
 Queensway Carleton Hospital Heart Failure Clinic
 Cornwall Community Hospital Heart Failure Clinic
Heart Failure/Cardiac
Rehabilitation
Programs – Hospital
& Community
 University of Ottawa Heart Institute Cardiac Rehabilitation Centre –
Inpatient & Outpatient Programs
 Cornwall Community Hospital Respiratory & Heart Failure Rehabilitation
Program – Outpatient
 Pembroke Regional Hospital Cardiac Rehabilitation Program – Outpatient
 Montfort Hospital Cardiac Rehabilitation Program – Inpatient & Outpatient
 Brockville General Hospital’s Cardiovascular Program
 Hawkesbury and District General Hospital Supervised Program
 Heart Wise Exercise (available throughout the Ottawa community at public recreation facilities)
Heart Health
Education
Complementary
Assets
 University of Ottawa, Prevention & Wellness Centre
 Regional Palliative Care Resources
 Geriatric Care Resources – Cognitive Impairment
Note: a regional search did not reveal any primary care best practice models for heart failure care delivery
3.3 Gaps in Heart Failure Care and/or Services
Utilizing the thought leadership of the multi-disciplinary task group, a gap analysis was undertaken of the existing programs and benchmarked against leading practices. Gaps were identified and grouped under three key heading as outlined in Table 5.
TABLE 5: REGIONAL GAPS IN HEART FAILURE CARE
CATEGORY
Education – Detection,
Assessment &
Management
Transitional Care
Access to Referral
Services
GAPS/CHALLENGES
 Recognition of early onset of heart failure
 Recognition of advanced/end-stage heart failure
 Recognition of cognitive impairment in heart failure patients
 Confidence in heart failure management at primary care level
 Lack of communication and timely coordination among healthcare professionals to ensure continuity of care
 Lack of standardization – discharge summary & care plan
 Medication reconciliation

Low awareness by primary care of available HF services and how to access services

Limited access to specialist for rural areas

Unattached patients – barriers to GP access
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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4.0 SUMMARY OF RECOMMENDED STRATEGY
4.1 Goal and Objectives
The overall goals of the heart failure strategy are to improve care and outcomes through:
1. Adoption of best practices
2. Reducing visits to emergency department
3. Reducing avoidable readmissions/admissions
4. Optimization of functional capacity and quality of life
These goals will be achieved through an investment in education, optimal service offering, transitional care and the detection, assessment and management of heart failure.
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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4.2 Strategy Components
NO. STRATEGY
1
COMPONENT
Comprehensive
Discharge
Summary including Care
Plan
(Transitional
Care)
2A
2B
The following table summarizes recommendation to support a regional integrated heart failure strategy. In developing recommendations, the group analyzed the current service provision and identified gaps/challenges . Please refer to section 4.2 for a detailed description of each of the strategy components listed below.
TABLE 6: SUMMARY OF RECOMMENDATIONS FOR A REGIONAL INTEGRATED HEART FAILURE STRATEGY
Expansion of
Home Monitoring
Program
(Transitional
Care)
RECOMMENDATION



Create a standardized discharge summary and plan for patients including pending tests (e.g. blood work) and medication reconciliation alongside best practice guidelines and clinical pathways.
Optimize and expand regional hospital infrastructure for home monitoring of high-risk heart failure patients.
Expand home monitoring initiative to Family Health
Teams (FHT)/Community
Health Centres (CHC) in the region.
ACTIVITIES
1. Conduct needs assessment through consultation with HF expert task group
2. Create a prototype and obtain feedback from task group
3. Automate prototype adding in built-in macros
4. Pilot test at UOHI (and revise as necessary)
5. Phase roll-out to our institutions
1. Review and update protocols
2. Conduct needs assessment to determine optimal distribution
3. Develop implementation and communications plan
1. Develop criteria/protocols to identify high-risk patients who should be monitored (as above)
2. Identify FHTs/CHCs who want to participate
3. Develop implementation and communications plan
4. Rollout pilot program and monitor
KEY
PARTNER(S)
Primary Care
Community Care
(CCAC and LTC)
UOHI and regional hospitals
UOHI, regional hospitals
UOHI
FHTs
CHCs
FUNDING SOURCES
In-kind $:

Development

Automation

Monitoring &
Evaluation
In-kind $:

Protocol development, needs assessment, implementation
External $:

Equipment
(monitors/modems)

Staff (RN, Coordinator)
 Monitoring &
Evaluation
In-kind $:

Protocol development, needs assessment, implementation
External $:

Equipment
(monitors/modems)

Staff (RN, Coordinator)

Monitoring &
Evaluation
PRIORITY
RANK
Very High
High
High
10
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY

NO.
3
4
5
STRATEGY
COMPONENT
IVR Follow-up
(Transitional
Care)
Dedicated
Transitional Care
Resource
Rapid Intervention
Clinic
RECOMMENDATION

Implement Interactive
Voice Response System
(IVR) using automated calling

Enroll all mild heart failure patients (who do not qualify for home monitoring) into the program upon discharge.
1. Revise current protocols to include early transition
2. Modify system algorithm
3. Implement and monitor performance (Year 1 – UOHI)
4. Develop engagement strategy for rollout to regional hospitals
5. Rollout to regional hospitals and monitor performance (Year 2)

Secure a transition care nurse who ensures continuity of care by assisting the patient transition from acute care
(specialist services) back into the community.

Develop strategy for acute decompensation and early intervention for patients seen through Heart Failure
Clinic or UOHI cardiologist to prevent ER visits and/or readmission (targets patients requiring intravenous diuretics and monitoring).
ACTIVITIES
1. Develop protocols and job description and hire dedicated nurse resource
2. Pilot test at UOHI and monitor performance (Year 1)
3. Rollout regionally (Year 2)
1. Build protocols
2. Hire and train HF nurses
KEY
PARTNER(S)
UOHI and regional hospitals
UOHI and regional hospitals
UOHI
FUNDING SOURCES
In-kind $:

Protocol development
External $:

Modification of system algorithm

Per patient fee

Staff (RN 1.0 FTE)

Monitoring &
Evaluation
In-kind $:

Protocol development, training
External $:

Staff (RN 1.0 FTE and
Clerk 1FTE)

Monitoring &
Evaluation
In-kind $:

Protocol development, training
External $:

Staff (RN 1.0 FTE and
Clerk 1.0 FTE)

Monitoring &
Evaluation
PRIORITY
RANK
High
High
High
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY

NO. STRATEGY
6
7
8
9
COMPONENT
Detection &
Assessment of
Heart Failure –
Screening Tool &
Criteria for
Referral
Cognitive
Impairment in HF
Patients –
Screening Tool &
Referral
Palliative Care for
Patients with advanced-stage
HF – Toolkit
Heart Failure
Management
Education –
Primary Care &
Community Care
Providers
RECOMMENDATION ACTIVITIES

Establish EMR-based screening criteria that helps providers assess early onset of heart failure, includes criteria for referral, and is linked to referral form should it be required

Develop EMR-based screening tool and algorithm that helps providers assess potential of cognitive impairment in
HF patients and is linked to referral form

Create toolkit that helps providers assess stage of
HF and need for palliative care service (to include screening tool in addition to tools for advanced care planning, management and referral).

Develop and implement accredited heart failure education plan for health professionals (physicians and nurse practitioners), inclusive of traditional and non-traditional delivery vehicles
1. Develop screening criteria based on Champlain Primary Care
CVD Prevention & Management
Guideline (heart failure section)
2. Solicit review and feedback by expert task group
3. Pilot with select primary care and community care providers; monitor and evaluate
4. Develop implementation strategy and broadly disseminate
1. Develop screening tool and algorithm (Geriatric Specialist)
2. Solicit review and feedback by expert task group
3. Develop implementation strategy including rollout, communication and education
4. Monitoring and evaluation
1. Develop screening criteria
(Palliative Care Specialist)
2. Solicit review and feedback by expert task group
3. Develop implementation strategy including rol-out and communication
4. Monitoring and evaluation
1. Conduct needs assessment at primary/community care level
(focus group)
2. Identify learning opportunities and preferred delivery format
3. Develop education modules
4. Obtain accreditation
5. Rollout
KEY
PARTNER(S)
Primary Care
Community Care
(CCAC and LTC)
UOHI
FUNDING SOURCES
In-kind $:

Screening Tool

Monitoring &
Evaluation
Geriatric Specialist
Primary Care &
Community Care
(CCAC & LTC)
UOHI
In-kind $:

Screening Tool
External $

Monitoring &
Evaluation
Palliative Care
Specialist
UOHI
Primary Care &
Community Care
(CCAC & LTC)
Primary Care
Community Care
(CCAC, LTC)
UOHI
In-kind $:

Palliative Care Toolkit
External $

Monitoring &
Evaluation
External $


Focus group
Education development and delivery
PRIORITY
RANK
High
High
High
Medium
12
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY

10
11
12
STRATEGY
COMPONENT
Community
Support Program
– Heart Failure
Increase knowledge of available services and referral access
Telemedicine
Expansion
Strategy
RECOMMENDATION

Establish multi-centre
Heart Failure Education
Program (modeled after the Diabetes program) to provide education and selfmanagement for patients, resources to physicians, management of HF patients, and expanded home monitoring services

Establish a central resource repository for heart failure services at
UOHI and in the region, inclusive of an algorithm to depict menu options of services and criteria

Develop clinical infrastructure to increase access of telemedicine services for rural areas)
(technological infrastructure exists).
ACTIVITIES
1. Conduct a regional needs assessment to identify requirements and locations.
2. Prepare detailed business case including action plan, resources and financial requirements.
3. Pilot program in one location
4. Rollout of program to the other two locations
1. Identify referral services at UOHI and the region.
2. Establish criteria for services such home monitoring, cardiac rehab, etc. and develop algorithm.
3. Develop implementation strategy including communications plan.
1. Assess the current situation
(SWOT analysis) and obtain utilization data on telemedicine services for heart failure
2. Conduct a regional needs analysis and assessment of capacity of telemedicine delivery to identify unmet service needs and locations of need.
3. Prepare action plan for recommended strategies to optimize telemedicine including financial requirements.
UOHI
Primary care
CCAC
KEY
PARTNER(S)
UOHI
Primary Care
(FHTs, CHCs, etc)
UOHI
Primary care
Specialty care
CCAC
LTC
FUNDING SOURCES
In-kind

Develop model and business case
External $

Staffing TBD

Other TBD

Monitoring &
Evaluation
In-kind

TBD
External $

Building of web-based repository
In-kind

TBD
PRIORITY
RANK
Medium
Medium
Medium
13
EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY

4.2.1 Description of Recommended Strategy Components
The following section provides an overview of the recommended strategy component. The recommendations, in most cases, have been substantiated with literature and linking evidence-based, best practices.
1. Comprehensive Discharge Summary including Care Plan
Inadequate transfer of information during care transitions plays a significant role in the problems of quality and safety for patients, contributing to duplication of tests and greater use of acute care services.
13 There is currently a variation in the information health care providers (e.g., primary care physicians, home care nurses, long-term care staff) receive, often resulting in clinicians across the health care continuum providing care without the benefit of having complete information about the patient’s condition, medical history, services provided in other settings, or medications prescribed by other clinicians.
Receiving practitioners need a standardized summary of the patient’s condition for the purpose of planning care and ensuring continuity of care and a smooth transition out of acute care. To ensure that the receiving care team has the essential information to assume management of the patient, a standardized discharge summary and care plan needs to be created including: conditions treated in hospital; patient goals; pending tests (e.g. blood work) and follow-up; medication reconciliation including changes in medications and rational for change; best practice guidelines and clinical pathways; and, the patient’s ability and confidence for self-care.
2. Optimization of Home Monitoring
The UOHI ’s Telehealth program is a home monitoring program that supervises patients through daily remote contact. It allows patients to stay in the comfort of their own home and participate in their care; resulting in improved patient quality of life and quality of care, and saved health dollars.
Patients are closely followed for up to three months after they are discharged using a portable home monitoring system. Patients are taught to measure and report their own vital signs daily. The data is transmitted via telephone to the Central Monitoring Station at the UOHI. If any information is questionable or if a patient asks for help, a nurse will call back immediately.
There are 15 regional hospitals in the Champlain region serving as satellite centres for the program with
3-5 monitors available per site for distribution to heart failure patients on discharge.
An evaluation of the program has identified that 30-day hospital readmission rates for heart failure patients have been reduced by 54% to 14.8% in the six-month period after the patients were tracked via telehealth monitoring. Savings up to $20,000 have been demonstrated for each patient safely diverted from an emergency department visit, readmission and hospital stay.
The program’s 150 monitors currently run at full utilization. There are a number of patients who do not receive this service due to unavailability of equipment or available referral issues. Clear criteria needs to be developed to identify high-risk heart failure patients who should be monitored. These updated protocols would be reviewed by all regional hospitals to support adoption and increased utilization.
In addition to program optimization and expansion in the hospital setting, it is recommended that the program be rolled out to participating FHTs and CHCs in the region to allow them to benefit from this initiative. Each participating primary care facility would receive up to two monitors and criteria for referral.
3. IVR Follow-up
Interactive Voice Response (IVR) telephone system through TelASK Technologies helps bridge continuity of care between hospital and home by closely monitoring patient recovery after hospital discharge. The
IVR system calls the patients at home during the recovery phase to ask a sequence of questions that screens for problems, such as adherence to diet and medications. Patients respond with natural speech and, depending on their answers, subsequent questions may branch into several new series. If a particular response – or combination of responses – suggests a problem, the call is transferred directly to a nurse at the UOHI who follows up with the patient.
It should be noted that the TelASK system offers more than IVR follow-up. It is a robust data management tool that could be set up to manage the overall program for the whole region. A variety of
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EXPERT TASK GROUP RECOMMENDATIONS REPORT

reports are available and the system can be configured to exchange data with patient management systems (primary care physicians) in FHTs. For example, the FHT could be notified if a patient decided to discontinue their medication.
IVR increases system efficiency by monitoring the post-discharge progress of patients and separating out those who need to speak to a nurse in person. Prompt intervention during recovery at home can avoid readmission to hospital. The IVR is also programmed to provide targeted education to patients. Best practices indicate that high-risk heart failure patients (those who have been admitted twice in the last year for heart failure, have continued learning needs, and/or low confidence that self-care can be successfully carried out) and patients of moderate risk (patients who have been admitted once in the past year, and/or low confidence to provide self-care successfully) should be followed-up within 48 hours 14 .
The current system algorithm requires updating to enhance early transition for post-acute follow-up and should be made available to all low-risk heart failure patients who are not part of home monitoring.
4. Dedicated Transitional Care Resource
Heart failure is the most common cause of hospitalization of people over 65 years of age. This patient group is representative of the growing segment of the population living longer with chronic health problems and experiencing breakdowns in care during multiple transitions from hospital to home that negatively affect their quality of life and consume substantial healthcare resources. Additionally, these patients typically have multiple co-morbidities, numerous disabling symptoms, complex medication regimens, and limited self-management skills 15 .
A formal program to manage the transition from acute care to the home setting for heart failure patients who have two or more complex medical conditions and a history of frequent readmissions is being recommended. This program, led by an advanced practice nurse, would be separate and distinct from ongoing case management which is currently the role of family physicians and the CCAC. This program would build on the evidence-based transitional care model 16 developed by Naylor and colleagues and modify it for the Ontario health care context. The program would include screening on admission; predischarge medication reconciliation; structured communication with pharmacists and family physicians at discharge and follow up with patients and family members to smooth the early transition; and, ensure discharge plans are well understood and support early engagement of new activities required as a result of the recent admission.
5. Rapid Intervention Clinic
The UOHI informally has a program whereby patients being seen through a Heart Failure Clinic or by a
UOHI cardiologist who are experiencing acute decompensated heart failure are provided an early intervention treatment (IV lasix, inotropes or transfusions ). Patients are placed on the ward for the day where they are treated and monitored. This intervention is designed to re-calibrate the care plan, treat an immediate problem, and prevent unnecessary visits to the emergency department or re-admissions to hospitals. Prompt treatment of acute decompensation can be life-saving. The program needs to be formalized with protocols developed and dedicated nurse resources to manage these acute cases.
6. Early Identification of HF –Screening Tool
Early detection and management of heart failure is important, but despite this, it is an under-diagnosed disease — symptoms can be non-specific and the clinical findings subtle. Based on the heart failure section of Champlain Primary Care CVD Prevention and Management Guideline, a screening tool needs to be developed to assist primary care practitioners in identifying patients with heart failure.
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7. Cognitive Impairment in HF Patients – Screening Tool
Cognition is a complex system involving multiple brain processes that allow an individual to perceive information (from both the internal and external environment), to learn and remember specific information, and finally, to use information previously processed to reason or problem solve in novel situations 17 .
There is increasing evidence of an association between chronic heart failure and cognitive impairment, resulting in worse health outcomes. Cognitive impairment is prevalent among elderly individuals with heart failure. Nearly half of patients with heart failure have problems with memory and other aspects of cognitive functioning, reports a study published in the Journal of Cardiac Failure 18 . And, as with heart failure, cognitive impairment is associated with increased use of health services and increased mortality 19 .
Seniors are generally able to manage their chronic conditions until they are affected by dementia. At that point, self-management is difficult and the individual enters a cycle of hospitalization, stabilization, discharge to home, poor self-management, deterioration in health, and re-admission to hospital. This cycle often repeats itself unnecessarily as health professionals fail to identify the mental health issue 20 .
Gender is an important consideration as significantly more women than men develop and live with dementias. Women older than 75 years constitute the fastest growing segment of the population and dementia is more prevalent in women with the female/male ratio of 2.7 according to the Canadian Study of Health and Aging.
Failure to recognize dementia has been attributed to lack of knowledge about dementia, lack of familiarity with cognitive screening, lack of symptom recognition, and the challenging psychosocial and ethical aspects of care for patients with declining cognition. A survey of 127 primary care physicians revealed that one-third were not confident about their ability to diagnosis dementia and two-thirds were not confident about their ability to manage dementia related symptoms 21 .
Screening for cognitive impairment is an essential step in the diagnosis and long-term management of heart failure. Unless purposefully screened for, cognitive impairment is largely hidden, making it difficult for many patients to independently recognize symptom changes and make appropriate self-care decisions 22 . Increased recognition of this significant co-morbidity is required to ensure improved patient health outcomes.
8. Palliative Care for Patients with Advanced/End-stage HF – Toolkit
Palliative care is an approach that aims to improve the quality of life of people with heart failure and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems (physical, psychosocial and spiritual) 23 . Numerous studies have documented the high utilization of health care resources in the last six months of life and the low rates of referral and utilization for end-oflife services during the last phase of life; other studies demonstrate the positive impact of improved screening and referral for end-of-life services such as palliative care 24 .
The task group is recommending a heart failure palliative care toolkit for primary care based on the UK
Gold Standard Framework (GSF) for Palliative Care, a systematic evidence-based approach to optimizing the care for patients nearing the end of life delivered by general practitioners. The GSF provides a framework for a planned system of care in consultation with the patient and family. It promotes better coordination and collaboration between healthcare professionals, helps to optimize care, and can prevent crises and inappropriate hospital admissions. The GSF improves communication, advanced care planning and monitoring of patients, and referral 25 .
In addition to a screening tool to assist primary care in identifying HF patients who would benefit from palliative care services, the toolkit would include: 1) tools for advanced care planning, including education modules for patients and professionals and a decision tool for preferred priorities of care; 2) module for management of end stage heart failure which would include education for family physicians and other community staff including PSW in LTC and home care developed collaboratively by UOHI, primary care, long-term care, geriatrics, and palliative care; 3) tool to assist primary care in making referrals to palliative care for consultation or for enhanced care; and, 4) module for managing the last days of life in the
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community and long-term care with emphasis on symptom control to prevent unnecessary hospital admissions.
9. Heart Failure Management Education – Primary Care & Community Providers
Heart failure is a complex condition to diagnose and manage and is becoming an increasingly important problem for primary and community care given the growing prevalence. Both settings have identified a gap in knowledge and the need for education. A needs assessment would need to be undertaken to determine opportunities and most appropriate delivery vehicle. Education would be accredited and provided to both physicians and nurse practitioners.
10. Community Support Program – Heart Failure Management
Deterioration of heart failure patients often relates to poor self-management and lack of patient knowledge about the condition. Effective self-management programs for patients with heart failure can reduce hospitalizations and mortality. There is an opportunity to develop a community support program for heart failure patients modeled after the Diabetes Education Centres (www.diabeteseducation.ca).
The program would provide heart failure patients with access to a multi-disciplinary team and essential education to help them stay in control of their health by teaching them about heart failure symptoms and treatment, and by helping them to manage the disease. This would benefit patients with heart failure who have difficulty staying on course and/or need additional support/education.
The Diabetes Education Centres are conveniently located in Community Health Centres (with certified diabetes educators in each rural hospital) throughout the region including rural areas where CVD mortality and risk are significantly higher. These Centres are accessible to all residents in the region through physician referral or self-referral. Similarly, a pilot is being proposed for heart failure. The program would be piloted in one centrally located CHC and then rolled out to two additional centres to ensure access is maximized. A detailed business case needs to be prepared to support the development of such a model and the Sandy Hill Community Health Centre has expressed strong interest in participating in the business case development and piloting of such an initiative.
11. Increase Knowledge of Available Services and Referral Access
Many health care providers in the Champlain region are unfamiliar with the range of heart failure services and programs available; i.e. when and how to access these services. The establishment of a web-based central heart failure repository that includes community- and hospital-based service options would help address this gap. The repository could also include tools, education material, up-to-date evidence-based guidelines, etc. The Diabetes Regional Coordinating Centre (http://www.champlaindrcc.ca) has recently released a dedicated site as proposed above.
12. Telemedicine Expansion Strategy
Rural areas in the Champlain region have significantly higher rates of CVD mortality and CVD risk factors.
Three of Champlain’s counties – Renfrew, Eastern Ontario (Prescott & Russell), and Leeds, Grenville &
Lanark - have been identified as Ontario hot spots for CVD morbidity and mortality. These counties experience rates of morbidity and mortality which are significantly higher than both the City of Ottawa and the provincial average. The increase in CVD mortality in these communities is also associated with higher prevalence of CVD risk factors. The rates of several key CVD risk factors (such as smoking, hypertension, and diabetes) in these counties are significantly higher than the provincial average 26 .
To make matters worse, these rural areas face limitations in their health care delivery systems. Generally, medical specialists such as cardiologists do not reside in these rural areas. Additionally, distance and limited transportation services often hinder the rural populations ’ ability to visit a cardiologist in Ottawa.
The UOHI has pioneered the use of telemedicine, a patient-centered approach, to overcome these infrastructural problems. Telemedicine is the practice of health care delivery, diagnosis, consultation and treatment, and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the patient, including audio or video communications sent to a health care provider for diagnostic or treatment consultation.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT

The UOHI has been providing local and regional telemedicine services for heart failure patients who don’t have to leave their homes for regular medical assessment and monitoring. However, the demand for this service is greater than what is being offered. There is an opportunity to expand this service and partner with CCACs and leverage their telemedicine platforms located in all major centres (Cornwall,
Hawkesbury, Pembroke, etc.) across the region. A detailed regional needs assessment of capacity needs to be undertaken to identify unmet service needs and locations for expansion.
5.0 Performance Management Plan
The following outlines performance measures (impact indicators) for the overall regional integrated heart failure strategy. However, specific process and outcome measures will be identified for each strategy component. It is also important to note that Health Quality Ontario is in the process of establishing metrics for readmission and ED visits. These will be revisited once released.
Nature of Impact
Reduction in avoidable ER visits for target population
Reduction in avoidable readmissions for target population
Reduction in avoidable readmissions/ER visits for target population
Performance Measure
Number of ED visits per year by target population
Number of avoidable readmissions per year by target population
Number of patients on
Guidelines Applied in Practice
(GAP) Discharge Tool
Source of Data
CIHI/LHIN
CIHI/LHIN
CIHI/LHIN
6.0 Leadership and Partner Roles
Partner Role
University of Ottawa Heart
Institute
Champlain CVD Prevention
Network
Primary Care –
FHTs and CHCs
Community Care
CCAC & LTC
Palliative Care
–

Serve as lead partner in the development of a regional integrated heart failure strategy and all strategy components

Provide on-going support for the strategy

Provide linkages to a variety of stakeholders

Participate in the monitoring of outcomes

Provide advice/expertise on issues/specifics related to respective sector

Test, adopt and champion new activities

Provide advice/expertise on issues/specifics related to respective sector

Test, adopt and champion new activities

Lead role in development of palliative care toolkit for HF patients at the primary care and hospital levels
Geriatric Care

Lead role in development of cognitive impairment tool for assessing
HF patients at the primary care and hospital levels
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EXPERT TASK GROUP RECOMMENDATIONS REPORT

7.0 Prioritization & Resources Requirements
It is recognized that while all of the proposed recommendations are important components of an integrated strategy, prioritization is necessary for strategy implementation. A decision priority matrix was designed for task group members to evaluate each recommendation on the following characteristics using a scale of 1-5 for a maximum score of 30:

Existing infrastructure and resources – are there resources and infrastructure already in place? Is existing service delivery infrastructure supportive of implementation?

Cost – how much funding is needed to implement?

Readiness – how ready is the recommendation for implementation? Does it require further planning and development?

Ease of implementation – how labour and time intensive is implementation? Do we have the necessary expertise and best practices?

Integration – does the recommendation facilitate a more efficient and coordinated system of care and span multiple sectors?

Potential for impact – how much of the heart failure population will benefit?
Based on their score, the recommended strategies have been assigned a priority rank as follows:
Very High = 25-30 High = 20-24 Medium = 15-19 Low = less than 15
It is, however, recognized that funding sources can at times dictate the level of priority.
ESTIMATED COSTS
RECOMMENDED
STRATEGY COMPONENT
Priority
Rank
Very
High
FUNDING
In-kind/
Partner

External
Funds Year 1
$0
Year 2
$0 Comprehensive
Discharge Summary &
Care Plan
Optimization/Expansion of Home Monitoring –
Hospital & Primary Care
Dedicated Transitional
Care Resource
HF Detection &
Assessment - Prescreening tool
Palliative Care Toolkit
High
High
High
High







$85,000*
$120,000
$0
$25,000
$85,000*
$120,000
$0
$0
Year 3
$0
$85,000*
$120,000
$0
$0
Cognitive Impairment –
Pre-screening Tool
IVR Follow-up
High
High




$25,000
$21,000**
$0
$20,000**
$0
$20,000**
Rapid Intervention Clinic High   $100,000 $100,000 $100,000
HF Management
Education – Primary
Care Providers
HF Services and Referral
Algorithm
Medium
Medium




$TBD
$35,000
$TBD
$0
$TBD
$0
Telemedicine Expansion
Strategy
Medium

$TBD $TBD $TBD
Community Support
Program – Heart Failure
Medium   $TBD $TBD $TBD
*Addition of 20 monitors per year over 3 years at $4,000/monitor and 5 modems per year at $900/ modem. Does not include staff resource.
**$1000 in year 1 to modify algorithm; first 400 patients cost $20,000 and $40 per additional patient. Does not include staff resource.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT

8.0 Impact
A comprehensive regional integrated heart failure strategy has the potential to improve outcomes including improved functional status and quality of life, enhanced compliance to best practices, decreased rates of re-hospitalization, and ultimately, decreased health care costs.
In 2010-11, the Champlain LHIN had greater than 1300 discharges from hospital for heart failure, with an unplanned re-admission rate of 22% within 30 days of discharge; this was 25-50% greater than expected based on the predicted probability of re-admission. The average length of stay in hospital is 10.4 days.
Indicators
2010-11
Actual
Modeling based on a
25% reduction readmissions
Modeling based on a
50% reduction readmissions
HF patients discharged 1300 1300 1300
30-day readmission rate
Number patients readmitted
22%
286
16.5%
215
11%
143
Number of admission avoided
Average length of stay /patient
-
10.4 days
71
10.4 days
148
10.4 days
Total hospital days saved 738.4 1539
An integrated strategy for heart failure in the region will produce more efficient care that provides economic benefits. For example, transition from hospital to home is challenged by frequent hospital readmissions, due to complexities of the patient, lack of integration among health care providers and limited community resources. There is a wealth of research evidence suggesting that interventions addressing patient- and system-level factors and integrating care can reduce hospital readmissions:
A successful strategy could be rolled out across the province and adapted to address other common readmission problems such as diabetes and other CVD, further extending the potential clinical and economic benefits.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT

9.0 Risk Assessment
As with any new undertaking, some degree of risk is involved. However, the risk of doing nothing and maintaining the status quo is far greater. Heart failure is a key disease of the elderly and with the aging population, the number of patients with heart failure is steadily growing; increasing the economic burden on an already stressed health care system. Innovative programs and solutions that reduce the cost burden of heart failure to the system must be a priority.
Type of Risk or Barrier
Adoption
Demand for recommended program components exceeds capacity
Insufficient resources to execute the heart failure strategy
Mitigation Strategy

Engage and involve key stakeholders in the development and implementation of program components.

Develop communication strategy and plan to be executed as part of the implementation phase.

Develop criteria for acceptance into program (i.e.
Home Monitoring, IVR, Rapid-Re-entry).

Maintain a short transition phase.

Establish good linkages with other support services.

Seek resources from network partners, in addition to government sources (e.g. MOHLTC and Champlain
LHIN) and industry.

Leverage UOHI ’s and CCPN’s track record of success and established relationships.

Scale-back high-cost programs; there are a number of components that involve a no-cost or a low- cost strategy.
EXPERT TASK GROUP RECOMMENDATIONS REPORT
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