A successful model for a heart failure clinic

Josep Comin-Colet

Barcelona, Spain

Improving Heart Failure Management: The 10 Things I Would Like To Change

A Successful Model for a Heart Failure Clinic

Josep Comín-Colet, MD, PhD Director of Integrated Heart Failure Management Programme at the

Barcelona Litoral Mar Integral Health Area (Barcelona)

#1. Heart Failure: Conceptual Framework

Real World Cardiac Patients

The ProblemChronic Heart Failure

Unmet NeedsSystem Designed for Acute Conditons

CHF

Profile

Prevalen

ce

Outcome

s

Costs

QoL

Understimation of economicand personal burden of

chronic conditions

Little adherence to Guidelines

Fragmented Care withoutcoordination Specialist-

Primary Care

Interventions led by physicians instead of other health care professionals

(nurses)

Promotion of Selfcare and empowerment of patients and

relativesUsually neglected

Interventions Not Planned

Short Visits for Acute ProblemsReactive Medicine

System designed for Acute Conditions

Real World Cardiac Patients

The ProblemChronic Heart Failure

Unmet NeedsSystem Designed for Acute Conditons

The AnswerChronic Care Model

CHF

Profile

Prevalen

ce

Outcome

s

Costs

QoL

Early Detectionof WHF

Evidence-basedManagement

StructuredFollow-Up

Empowermentof Patients

Integrated and Coordinated

Delivery of Care

CONTINUITY of CARE

↓Mortality & Hospitalizatio

n

↑HRQoL

Heart Failure Programmes

• Heterogeneity of organizational models

• Heterogeneity in outcomes: no «Class Effect»

• Applicability in «real world » has been questionned

#2. Organization of Multidisciplinary Care

The Barcelona Experience

7.5M inhabitants (98%)€ 8,000 M Healthcare Budget

Catalan Health Service (CatSalut)6 Health Regions /44 Integrated Health Areas

Barcelona1.6 Million inhabitants

4 Integrated Health Areas

Integrated Health AreaMultilevel & multiprovider health care

coordination for a population of 350,000 inhabitants

#3. Needs Assessment

“10 things I would like to change”

SelectedSTAGE C-DSelectedSTAGE C

“Hospital BasedHF Units”

Most HF-REF Patients (StageC)

General Cardiologisttogether with PC

Most HF-PEF Patients (Stages C) and Most Stage D patients (either HF-REF

or or HF-PEF)Primary Care

D: Advanced HF Units

PrimaryCare

C and D: MD HF Units

Diagnosis

Long-termManagement

1) Easy access to expert opinion and advise

2) Education and Training in a regulars basis (mentorship)

3) Contribution of Primary CareProfessionals in the creation, development and fine-tuning of especific and local HF carepathways (agreement)

4) Clinical leadership at a local level(HF care pathways leaders)

5) Enabling a more active role of specialist nurses (case managers)

Primary Care Specialists

1) Hospital Managers promoting the creation of HF services with organizational autonomy and executive capabilities

2) Active role in supervising the health care pathway for critical decisions about management

3) Focus the specialist in giving suportfor most cases and active role in those requiring more expert management

4) Productive regular interactions with primary care (training and coordination of care)

5) Specialized nurses actively involved in care and coordination

#4. Building up the Programme

HF Nurses

Case ManagersWorking

Group andExecutiveCommitee

Primary Care component: 14 PCC w/ Health Care Pathway leaders + Integrated Specialized Care

Hospital component: Multidisciplinary HF Unit

(Cardiology)

Progressive implantation bewteen 2005 and 2011

HF Health Care Pathway

Organization of the Barcelona Litoral Mar IHFP

HEART FAILURENURSES

CARDIOLOGISTS

CARDIOLOGY

TEAM

Primary Care PhysicianPC Nurse

GeriatricianSuport ServicesAcute Beds

Liaison Nurse

Case Managers

SOCIAL WORKER NEURO-

PSYCHOLOGIST

PALLIATIVE CARETEAM

REHAB DOCPHYSICAL THER.

OCCUPATIONAL THER.

Suport Services toHospital Based HFP

MULTIDYSCIPLINARYTEAM APPROACH

WHO?

IN- HOSPITAL

OUTPATIENT- CLINIC

PRIMARY CARE

WHERE?

SELF CARE SUPPORTIVESTRATEGY - EDUCATION

EXERCISE TRAINNINGPROGRAM

PSYCHO-SOCIALEVALUATION-SUPPORT

OPTIMAL RxFLEXIBLE DIURETIC

EASY & QUICKACCESS TO TEAM

ACTIVE FOLLOW-UPAPPOINTMENTS

PHONE CALLS

ESC GUIDELINES

HOW?

ML-IHFP

PHARMACISTS

Clinical Psychologist

TELEMEDICINE

#5. Key Components

To achieve a successful implementation of Multidisciplinary Coordinated Care for Heart failure

Nurse-Based Interventions HF Nurses and Primary Care Case Managers

PsychosocialFactors

Evaluation•cognition

•Autonomy/Dependency•Social Support•Affective Status

•QOL•Physical Barriers

Competent Caregiver

activate & coordinateTeam interventions

Coordination w/PCTransitions

Case Managers

Clinical Pathway

HF Nurse Staff Nurse

Clinical Pathway

Knowledge About

HF

evaluation

intervention

EducationEmpowerment

Shared Electronic Medical Records & Services

Liason Nurse

HFU

IH

OP

HF nurse

Day H

PC

PC CAR

GP & N

CALLCENTER

Home Care Team

Case ManagersTelemedicineTeam

Expert PatientProgramme

PalliativeCareTeam

Nurse-Based Structured Follow-Up with Clinical Pathways and Check listsHome-based/HF Clinic Based/+ Telemedicine

Patient Road MapHand Over on Transitions

#6. Outcomes

Key Performance Indicators (KPI) for the Public Health Care System in Catalonia

Division of Registries of Activity and Demand : Catalan Health Service

Results of Our Programme: Population-based data

adjusted

Temporal Trends of Cardiovascular Readmission (30 days)

Heart Failure Readmissions at 30 days

Hazard Ratio: 0.551 ; 95% CI (0.411-0.692)

compared to CatSalut

6-month (clinically-related) readmission: 2014 Benchmark

#6. Challenges For MDT Working

Barriers To Overcome

SYSTEMIC BARRIERS1. Increase the awareness of heart failure as a problem for patients and for the sustainability of

public healthcare systems2. Increase the awareness among healthcare services managers and healthcare professionals

that MDT management and integrated care are the best approaches for HF patients 3. From a societal perspective, place the importance of heart failure at the same level of other

important chronic conditions such as cancer

INSTITUTIONAL BARRIERS1. Promote the creation of truly integrated healthcare pathways and clinical processes for HF

patients (local settings) with professional teams working at various levels of care 2. Healthcare pathways for the management of HF (functional teams) with organizational

autonomy and executive capacity (support form managers and healthcare authorities)3. Promote the access of professionals involved in the care of HF patients to quality indicators

and to participate in the process of creation of MDTs

PROFESSIONAL BARRIERS1. Increase TEAMWORK culture among healthcare professionals 2. Allow shared leadership 3. Training, training, training (at all levels of care) 4. Health and social integration (in MDT teams but also in early stages of training and education)

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