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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