lhin chsp – cardiac pag · • monitoring via cihi, ices, ccn • lhin-wide quality approach...

LHIN CHSP – Cardiac PAGSubmission Draft

July 3, 2009

Attendees: Meeting 1

• Dr. Jim Bulger• Ms. Barbara Busing• Dr. Stuart Connolly• Dr. Hugh Fuller• Ms. Sue Gregoroff• Dr. Murtaza Gulamhussein• Dr. Doug Holder• Dr. Ted Mitchell• Dr. Khal Salem• Mr. Brady Wood (Facilitator)


• Dr. Jim Bulger• Ms. Barbara Busing• Dr. Hugh Fuller• Ms. Sue Gregoroff• Dr. Murtaza Gulamhussein• Dr. Doug Holder• Dr. Ted Mitchell• Dr. Khal Salem• Dr. James Velianou• Mr. Brady Wood (Facilitator)


• Dr. Jim Bulger

• Dr. Hugh Fuller

• Ms. Sue Gregoroff

• Dr. Doug Holder

• Dr. Ted Mitchell

• Dr. Khal Salem

• Dr. James Velianou

• Mr. Brady Wood (Facilitator)

Template 1: Strengths and Challenges within the Current System in Addressing Population Needs

Strengths Challenges

Collaboration among partners (e.g. LHIN Cardiac Working Group); willingness to modify practices

eHealth Inftrastructure (e.g. shortcomings of EHR)

Acute Infrastructure in place• Full spectrum of care exists in LHIN

Coordination (continuum; transitional; what can occur in the community v. in hospital) and Integration (v. fragmentation)

Availability of Data (e.g. CATH, PCI, ICD, Wait Times) and Data sharing Lack of integration of chronic care (e.g. management of chronic heart failure; primary/secondary rehab)

Strong Research (particularly Hamilton) and Innovation Knowledge Translation and Delivery Research (e.g. best practices)

Education Programmes (e.g. fellows; primary care) Access (To cardiac rehab; to tilt-table tests)

Coordination• timely access to CATH, Angio• user-friendly; one number for interventional cardiology

EMS Issues• Transfer time• Uniformity of training and skills

Availability of Angio Consistent quality of care

Priority funded program Wait times• No single wait list for cardiologists • Limiting to routine cardiac care•Data for outpatient cardiac

EPS/ Cardiac surgery Rural Access (distance from Rural communities to centres + disease burden)

Specialty clinics Role clarity (e.g. cardiac v. GIM)

CCN memberships Resourcing – under resourced in many areas

Prevention and Wellness

Patient automobile/driving issues (e.g lack of template)

Template 2: Factors most likely to increase / decrease future demand for health care:

Describe the factor that will increase or decrease demand by 2013 Will this factor have a modest or significant impact on future demand?

Aging population (e.g. baby boomers) ; age demographics by community Significant

Shift to greater incidence of chronic disease with longer lifespan Significant

Manpower planning and declining enrollment (physicians, nurses) Modest

Increasing enrollment for cardiology Modest

Patient expectations; more informed “consumer” Significant

New technologies (e.g. 64 swlice CT/Angio; artificial heart); inappropriate use of technology Significant

Socio-economic correlates to heart health (lifestyle, aging, cultural) Significant

Under-serviced communities (in particular – aboriginal) Modest

Chronic disease management could decrease demand Modest

Prevention initiatives could decrease demand Modest

Primary care models Modest

Economy – growth of demand v. tax base Significant

Component Services associated with this component

Clinical and non-clinical interdependencies

Linkages to community services

Health Promotion/Disease Prevention

• Smoking cessation/education• Parallel weight loss and nutrition • Healthy environments • Consciousness at planning tables

• Primary and secondary prevention• Anti-obesity: community/med/surg• Workplace programs • Diabetes/metabolism/endocrine

• Fitness centres• Weight loss programs/nutrition• Primary Care • City Hall/planning

Primary Care • Standard protocols • Best practice informationavailable • Consistent approach to quality, breadth, and access to Cardiac and DI• Clarity of expectations/ education/ guidelines • Linkages to specialty care • Counseling on prevention • Early intervention approach • LHIN-wide lab

• Full range of Acute Care • EMS• ERs • Prevention and health promotion • Laboratry

• EMS• Hospitals • Nutrition / weight loss • Fitness centres• Community labs

Pre-hospital Care • Consistent EMS standards, training and protocols• Ability to collect and report data (portal) • Centralized model

• Primary care• Hospitals• ERs • LTC/Home Care

• Addiction and Wellness resources

Acute Hospital Care • Full range of acute cardiac -exists• Equitable access to services of comparable quality• Standardized protocols • Enhanced dialogue and knowledge transfer between centres• Rapid access to PCI• Clinical connects portal; standard data collection

• Primary care• between Hospitals• ERs • LTC/Home Care • Prevention and health promotion • Laboratory• Prevention and health promotion

• EMS• Hospitals • Nutrition / weight loss • Fitness centres• Community labs• LHIN • Mental Health and Addictions linkages must be stronger

Template 3: Components of an Ideal Service Delivery Model

Component Services associated with this component

Clinical and non-clinical interdependencies

Linkages to community services

Non-acute hospital care • Nutrition services • Rehabilitation

• CCU/CTU/ICU• ER / Urgent Care

Post-hospital Care • CCAC assessment • Home Care• Primary Care • Nutrition/wellness • ER/Urgent Care • Outpatient Cardiac Rehab

• CCU/CTU• Other acute areas (surgical step-down) • CCAC and referral orgs.

• Home Care • Nutrition/wellness

Community-based Non-acute Care • Outpatient Cardiac Rehab • Home Care • ER/Urgent Care

• CCU/CTU/ICU• ER / Urgent Care • CCACs

• Home Care

Chronic Disease • Multi-disciplinary hospital andcommunity chronic disease management

• All acute care• Primary Care• Post-hospital stay

LHIN-Wide EPortal • Electronic Referral and Booking System • Electronic Records

• System-wide

LHIN-Wide approach to Quality / Assessment and Standardization ofCardiac Diagnostics

• Including •Standardized protocols• Data quality control for Cardiac diagnostics • Formalized patient feedback

Multidisciplinary Ambulatory Care Centres with Cardiology Teams

• Delivering services outside of hospital settings• Multi-disciplinary team approach

• Principles for development • Primary Care• Acute Care • Specialists Offices • CCAC • Mental Health and Addictions (e.g. Depression, anxiety, smoking cessation resources)

Template 3 Continued: Components of an Ideal Service Delivery Model

Khal’s Diagram

Diagram: LHIN 4 Cardiac Services – Ideal State

Principle: equitable access to services of comparable quality across the LHINBased on: Current LHIN-Wide Centre Provision Model – Page 6 PAG Reviews Document

QuaternarySite

Tertiary Site

Tertiary Site

Tertiary Site

Tertiary Site

*

*

*

*

*

*

*: Hemodynamically stable; Monitoring only


Overarching Quality, Safety and Best Practice Framework, driven by Quaternary Centre, in dialogue with Other Facilities

QuaternarySite

Tertiary Site

Tertiary Site

Tertiary Site

Tertiary Site

*

*

*

*

*

*


QuaternarySite

Tertiary Site

Tertiary Site

Tertiary Site

Tertiary Site

*

*

*

*

*

*

LHIN-Wide EPortal (Records and Referral System)

OutptCardiac Rehab

CCAC

One Stop

Outpt

Long-Term Care

Diagram: LHIN 4 Cardiac Services – Ideal StateLocal Services

SUPPORTS

•Academics: robust hub/spoke dialogue and knowledge translation

•Quality: centralized approach to quality and performance data

•LHIN-Wide EPortal (Records and Referral System)

• Prevention and Early Detection Approach

-Comprehensive Smoking Cessation Program - Parallel Obesity and Nutrition Strategy (e.g. Provincial) -Parallel Aboriginal Health Strategy (e.g. Provincial)

• Standardization: standardization of practices across the continuum

OutptCardiac Rehab

CCAC

Lifestyle Mgmt

One Stop

Outpt

Home

Long-Term Care

Primary Care

EMS

Amb Care Centre(s)

• Intake sessions• Risk factors assessment • Smoking cessation • Dietician • Intake questionnaire • Exercise prescription• Graduation• Weight management

Potential free/subsidized membership

• Outpatient intake assessment (questionnaire and measurement) • Home exercise program assistance • Heart failure management partnership weighing and liaison with physicians at the cardiac rehab

Potential free/subsidized membership

Diagram: LHIN 4 Cardiac Services Ideal State – OrganizationCardiac Prevention Alliances

Weight Management/ Ontario

bariatric stat

Cardiac Rehab

CCAC

Fitness Centre (E.G.

ymca)

One Stop Outpatient

•Post Angiography• Post CABG• Post MI• Primary prevention for >1 risk factors• Obesity Management• Heart failure rehab

•Stress tests• Holters• LOOPs•Follow-up on CHF

Khal’s Evaluation Tool

Template 4: Assess the recommended model against the criteria

Cardiac PAG DOMAIN CRITERIA ASSESSMENT DESCRIPTION

Strategic Fit Alignment with LHIN priorities for health improvement

•Aging At Home: restoring people to health as soon as possible and returning to outpatients; specialty clinic support (e.g. heart function); Linkages with CCAC (transitional care for heart failure and COPD); chronic disease management • ER/ALC: reduce LOS, standardization protocols /discharge plans (AMI), management, EMS transport improvement for primary PCI/other emergency cardiac care; defer admissions via ER through robust primary care services• Mental Health and Addictions: need for increased resources for acute cardiac patients including psychiatry, addictions, smoking cessation • Right Care, Right Place, Right Time: move patients to less resource intensive environments where possible (i.e. focus on prevention, ambulatory and outpatient settings); enhances coordination and resources for Primary Care and other areas of the system

Alignment with trends in health care needs and system transformation

• eHealth: consistent/progressive• Enhances collaboration and integration between providers• Adds much needed infrastructure, and wellness programs• Management of Cardiac patients: • In comparison to template 2, the model addresses the significant factors

Template 4 continued: Assess the recommended model against the criteria


Population Health Health Status (clinical outcomes and QOL)

• Outcomes should improve – e.g. via heart failure clinics, improve access/quality of diagnostics, more robust prevention• Monitoring via CIHI, ICES, CCN• LHIN-Wide quality approach suggested • Data is an opportunity for improvement in the current model • LHIN 4 Cardiac Working Group – Smart AMI Project principles could be applied more broadly • LHIN 4 is ahead of the curve due to existing communication and collaboration • Funding for quality insurance is an area for improvement

Prevalence • Prevalence will be increasing; model recognizes this and suggests a model to mitigate • Prevalence may also be seen as an indication of success (people living longer)

Health promotion and disease prevention

• Alliance (one stop) • Room for improvement with better application of guidelines to target (diabetes, hypertension) i.e. Knowledge translation• Cost of drugs as area for improvement (e.g. better use of generics)• Working poor in our area • Clear integration with CCAC• Informing public policy (e.g. linkages to medical profession and government)



System Values Patient-Focus • One stop/ ambulatory principles

• EMS strategy – improve access at time they need it most\• Proximity to service v. need

Partnerships • identified and strengthened external linkages• Communication/referral through e-Portal • Local and provincial systems (CCN, ICES)• One of most robust research programs • Learners across system • Universities, colleges, and med schools (McMaster, Brock, Michener, Mohawk)• Relations between hospitals

Community Engagement • Patient education • Specialty clinics in communities • Primary PCI • Need for explanation of decision making and mechanisms for citizen engagement and feedback

Innovation • Research and knowledge translation• Communication (E-Portal)• Largest Primary PCI program in country; largest advanced cardiac care provincially/nationally • Integrated community partnerships • Patient-focused and assessment (cultural) (e.g. PAVR, endovascular management, minimally invasive approaches – e.g. mitral valve surgery)•One stop cardiac

Equity • Founding principle of our work• Consistent care reinforced by LHIN-Wide quality approach •Aboriginal strategy

Efficiency (operational) • Protocols to avoid duplication to streamline care as appropriate • LHIN-wide quality management



System Performance Access • Enhanced via E-Portal referral and records system

• Free up acute resources by treating in outpatient and ambulatory for appropriate cases• More coordinated and central approach focused on care continuum and value for patients

Quality • Includes enhanced LHIN-wide approach to quality and safety, synched with academic programs to ensure best practices and knowledge translation• Also includes formal monitoring and feedback mechanisms

Sustainability • Resource-intensive model, however costs are likely to be found in acute care centres after the implementation of One Stop Outpatients and Ambulatory Teams• eHealth infrastructure is likely to be costly, but should be funded centrally; must include ePortal for both records/DI and referrals • Requires pooling of Quality infrastructure from multiple organizations to ensure consistent approach

Integration • Builds on success hub-and-spoke model in place today; good/enhanced synergies between academic and clinical (knowledge translation)• Enhanced through common approach to quality and measurement• Common system for records/DI and referrals• Supported by linkages with primary care and ambulatory teams

Template 5: Descriptions of Pre-requisites, Enablers, and Challenges to Implementation

CATEGORY PRE-REQUISITES ENABLERS CHALLENGES

POLICY • Government rural hospitals group (e.g. examining levels of service for rural communities) • Change Public Hospitals Act re: nurse practitioners and nurses • Obesity/Nutrition and Smoking Cessation • EMS funding inadequate (via municipalities)

• Expedited process re: driving • Current financial downturn• Potentially lacking political will as we head into campaigning year

LEGISLATION •N/A •N/A •N/A

AVAILABILITY of RESOURCES

• Obesity / Nutrition and Smoking Cessation • Funding for specialized advanced cardiac procedures /surgeries • Hear failure clinics • Cardiac Rehab • Mental Health and Addictions sync critical • Quality and Standardization and Assessment

• Political will• Commitment by administrators and clinicians to realign resources in support of enhanced cardiac model • Willingness on part of clinicians to find efficiencies in their practice

• Current financial downturn• Potentially lacking political will as we head into campaigning year•

READINESS • E-Health resources which are currently not in place• willingness on the part of clinicians to practice in different ways• prevention focus at the Provincial and Federal level (i.e. cannot have adequate prevention without a convincing smoking cessation or weight loss program)

• Political will for large effective expenditure for electronic infrastructure • Administration of different healthcare corporations

•Health human resources• E-Health infrastructure • EMS • Funding limits / financial downturn

LINKAGES • E-Health Infrastructure (Records/DI and Referral System) • Mental Health and Addictions colleagues• Diagnostic Imaging colleagues

• Administration of different healthcare corporations • Primary care leadership

• E-Health Infrastructure

OTHER:

lhin chsp – cardiac pag · • monitoring via cihi, ices, ccn • lhin-wide quality approach...

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