Heart Function ClinicsAnnemarie Kaan MCN RN CCN(C) CCTN

Clinical Nurse Specialist

Heart Failure and Transplantation

St Paul’s Hospital, Vancouver

Outline

• History• What do HFCs do?• What do the guidelines say?• Patient teaching/coaching• BC Heart Failure Network• Referring• The future

History• Multidisciplinary clinics

– 1970s and 80s• Edmonton

– Mid ’90s• Surrey

– Late1990s• St Paul’s HF Clinic

– 1999– It’s FUNCTION, not FAILURE!

• VGH– 2008

Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2-4.

So what exactly do HFCs do?

• Provide access to other specialties– ICD/PM– CRT– TAVI– Surgery– Palliative care

• Multidisciplinary team

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.

Which HCPs are essential members of any HF MDT?

Patients and their families should be fully involved in making decisions throughout the care pathway

The key team

Cardiologist/ internistSpecialist Nursing team:

RNsAdvanced Practice (NP/CNS)

Primary Care

Patient-dependent specialists

Pharmacist Dietitian Geriatrician Physiotherapist Psychosocial team

Other specialists

Palliative care remains an option throughout the care pathway in HF and not only for patients at the end of their lives

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.

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.

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.

Patient Teaching

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

https://www.fin.gc.ca/pub/eficap-rebvpc/report-rapport-eng.asp

Gov’t Canada website – June 2016

Heart Failure Think Tank 2009

• Provincial Advisory Panel for Cardiac Health– Think tank– Recommendations

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

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

Cardiologists/InternistsGuideline driven care

ProvincialHub:

Acute HF Program

SPH

VIHARJH

HFCs

CDMs

Internists

IHNs

SpecGPs

Inter

iorKG

H HFCs

CD

Ms

Intern

ists

IHNs

Spec

GPs

NorthernPGH

HFCs

CDMs

Internists

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

VCHSPH

HFCs

CDMs

Cardiologists/

Internists

IHNs

SpecGPs

VCHVGH

Fraser

RCH

HFCs

CDMs

Internists

IHNs

SpecGPs

Fraser

Surrey

Acute HF servicesClinical supportGuideline DevelopmentEducation

Referring

• No show rate 10% or more in VGH and St Paul’s– Why?

* Inadequate information

* Socio-economic

* Cultural

* Distance

* Multiple comorbidities

* Mobility/age

Where should I refer? – tips

1. Potential transplant candidate?• Age, other options, comorbidities St Paul’s (consult and follow up plan)

2. Do they need high level HF care?• ICD, CRT other devices Regional hub

3. Age/mobility/distance/personal preference? Local HFC

The future…

• Care in the home• Centralized triage

– One referral number

• Increased partnership with primary care• Partnerships with other chronic disease programs

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