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CHAMPLAIN CVD PREVENTION
STRATEGIC PLANNING 2013-2016
EXPERT TASK GROUP RECOMMENDATIONS REPORT
REGIONAL INTEGRATED HEART FAILURE
STRATEGY
FINAL REPORT
JUNE 2012
EXPERT TASK GROUP MEMBERSHIP
TABLE 1: HEART FAILURE EXPERT TASK GROUP
Name
Title & Organization
Heather Sherrard,
co-chair
Vice President, Clinical Services, University of Ottawa Heart Institute
Dr. Lisa Mielniczuk,
co-chair
Assistant Professor of Medicine, University of Ottawa
Division of Cardiology, Heart Failure and Cardiac Transplantation
Co-Medical Director, Pulmonary Hypertension Clinic
Kim Peterson
Vice President of Client Services, CCAC
Eleanor Wright
Director of Emergency & ICU, Pembroke Regional Hospital
Susan Coulas
TeleMedicine, CCAC Nursing and Pre-Op Clinic, & Inservice Coordinator &
Pharmacy Nursing Supervisor, St. Francis Memorial Hospital (Barry’s Bay)
Arlene Thomson
Program Director, Cardiovascular Services, Thunder Bay Regional Health
Sciences Centre (Aboriginal Perspective)
Sheila Bauer
Long-Term-Care(LTC) Home Administrator, Peter D. Clark at City of Ottawa
Dr. Robert Bourrier
Family Physician, Sandy Hill Community Health Centre
Dr. Nahid Azad
Geriatric Medicine, Professor of Medicine, University of Ottawa
Christine Struthers
APN Cardiac Telehealth, University of Ottawa Heart Institute
Dr. John Scott
Palliative Care, University of Ottawa Heart Institute & The Ottawa Hospital
Dr. Judy Chow
Primary Care Physician, Rideau Family Health Team
Norvinda Rodger
Network Manager & Senior Planner, Champlain CVD Prevention Network
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
TABLE OF CONTENTS
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
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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 Canada2. 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 productivity3.
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 system4.
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 hospital5. Early
identification and treatment of heart failure in primary care is critical to preventing an avoidable ED visit.
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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]
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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 residents8.
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-admission10;
 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
Females
AGE
GROUP
Males
2006
2007
2008
2009
2006
2007
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 conditions11.
TABLE 3: AGE-STANDARDIZED HOSPITALIZATION RATES (PER 100,000 POPULATION) FOR
CITY OF OTTAWA, EASTERN COUNTIES, AND RENFREW COUNTY, 2006-2009
Heart Failure
City of Ottawa
Eastern Counties
Renfrew County
2006
131.9
223.5
218.2
2007
124.3
216.8
197.3
2008
121.6
206.8
192.8
2009
128.1
205.3
183.8
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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 Study12,
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:

Percentage 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%).
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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

University of Ottawa Heart Institute Home Telehealth, Telehome Monitoring
and Interactive Voice Response (automated calling)
Evidence-based
Clinical Guidelines


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
GAPS/CHALLENGES
Education – Detection,
Assessment &
Management





Transitional Care
Access to Referral
Services





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
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
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.
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
4.2 Strategy Components
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
NO.
1
2A
2B
STRATEGY
COMPONENT
Comprehensive
Discharge
Summary
including Care
Plan
(Transitional
Care)
Expansion of
Home Monitoring
Program
(Transitional
Care)
RECOMMENDATION
ACTIVITIES
KEY
PARTNER(S)
FUNDING SOURCES
 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.
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
Primary Care
Community Care
(CCAC and LTC)
UOHI and regional
hospitals
In-kind $:
 Development
 Automation
 Monitoring &
Evaluation
UOHI, regional
hospitals
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
UOHI
FHTs
CHCs
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
 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.
PRIORITY
RANK
Very High
High
High
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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
ACTIVITIES
KEY
PARTNER(S)
FUNDING SOURCES
PRIORITY
RANK
 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)
UOHI and regional
hospitals
In-kind $:
 Protocol development
High
 Secure a transition care
nurse who ensures
continuity of care by
assisting the patient
transition from acute care
(specialist services) back
into the community.
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)
UOHI and regional
hospitals
 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).
1. Build protocols
2. Hire and train HF nurses
UOHI
External $:
 Modification of system
algorithm
 Per patient fee
 Staff (RN 1.0 FTE)
 Monitoring &
Evaluation
In-kind $:
 Protocol development,
training
High
External $:
 Staff (RN 1.0 FTE and
Clerk 1FTE)
 Monitoring &
Evaluation
In-kind $:
 Protocol development,
training
High
External $:
 Staff (RN 1.0 FTE and
Clerk 1.0 FTE)
 Monitoring &
Evaluation
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
NO.
STRATEGY
COMPONENT
6
Detection &
Assessment of
Heart Failure –
Screening Tool &
Criteria for
Referral
7
Cognitive
Impairment in HF
Patients –
Screening Tool &
Referral
8
9
Palliative Care for
Patients with
advanced-stage
HF – Toolkit
Heart Failure
Management
Education –
Primary Care &
Community Care
Providers
RECOMMENDATION
ACTIVITIES
KEY
PARTNER(S)
FUNDING SOURCES
PRIORITY
RANK
 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
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
Primary Care
Community Care
(CCAC and LTC)
UOHI
In-kind $:
 Screening Tool
 Monitoring &
Evaluation
High
Geriatric Specialist
Primary Care &
Community Care
(CCAC & LTC)
UOHI
In-kind $:
 Screening Tool
High
Palliative Care
Specialist
UOHI
Primary Care &
Community Care
(CCAC & LTC)
In-kind $:
 Palliative Care Toolkit
Primary Care
Community Care
(CCAC, LTC)
UOHI
External $
 Focus group
 Education
development and
delivery
 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
External $
 Monitoring &
Evaluation
High
External $
 Monitoring &
Evaluation
Medium
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EXPERT TASK GROUP RECOMMENDATIONS REPORT – REGIONAL INTEGRATED HEART FAILURE STRATEGY
STRATEGY
COMPONENT
10
Community
Support Program
– Heart Failure
11
Increase
knowledge of
available services
and referral
access
12
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
KEY
PARTNER(S)
FUNDING SOURCES
PRIORITY
RANK
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
UOHI
Primary Care
(FHTs, CHCs, etc)
In-kind
 Develop model and
business case
External $
 Staffing TBD
 Other TBD
 Monitoring &
Evaluation
Medium
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
Specialty care
CCAC
LTC
In-kind
 TBD
Medium
UOHI
Primary care
CCAC
In-kind
 TBD
External $
 Building of web-based
repository
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
14
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 hours14.
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 skills15.
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 model16 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.
15
EXPERT TASK GROUP RECOMMENDATIONS REPORT
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 Failure18. 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 symptoms21.
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
decisions22. 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 care24.
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 referral25.
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
16
EXPERT TASK GROUP RECOMMENDATIONS REPORT
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 average26.
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.
17
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
Performance Measure
Reduction in avoidable ER
visits for target population
Reduction in avoidable
readmissions for target
population
Reduction in avoidable
readmissions/ER visits for
target population
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
University of Ottawa Heart
Institute
Role
 Serve as lead partner in the development of a regional integrated heart
failure strategy and all strategy components
Champlain CVD Prevention
Network
 Provide on-going support for the strategy
 Provide linkages to a variety of stakeholders
 Participate in the monitoring of outcomes
Primary Care –
FHTs and CHCs
 Provide advice/expertise on issues/specifics related to respective
sector
 Test, adopt and champion new activities
Community Care –
CCAC & LTC
 Provide advice/expertise on issues/specifics related to respective
sector
 Test, adopt and champion new activities
Palliative Care
 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
18
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
FUNDING
In-kind/ External
Partner
Funds
RECOMMENDED
STRATEGY COMPONENT
Priority
Rank
Comprehensive
Discharge Summary &
Care Plan
Optimization/Expansion
of Home Monitoring –
Hospital & Primary Care
Dedicated Transitional
Care Resource
Very
High

High

High

HF Detection &
Assessment - Prescreening tool
Palliative Care Toolkit
High

High

Cognitive Impairment –
Pre-screening Tool
High
IVR Follow-up
Year 1
Year 2
Year 3
$0
$0
$0

$85,000*
$85,000*
$85,000*

$120,000
$120,000
$120,000
$0
$0
$0

$25,000
$0
$0


$25,000
$0
$0
High


$21,000**
$20,000**
$20,000**
Rapid Intervention Clinic
High


$100,000
$100,000
$100,000
HF Management
Education – Primary
Care Providers
HF Services and Referral
Algorithm
Medium


$TBD
$TBD
$TBD
Medium


$35,000
$0
$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.
19
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.
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
22%
16.5%
11%
Number patients readmitted
286
215
143
Number of admission avoided
-
71
148
Average length of stay /patient
10.4 days
10.4 days
10.4 days
738.4
1539
Indicators
Total hospital days saved
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.
20
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
Mitigation Strategy


Demand for recommended program
components exceeds capacity



Insufficient resources to execute the
heart failure 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.
21
EXPERT TASK GROUP RECOMMENDATIONS REPORT
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20
House of Commons Standing Committee on Health. Report 8 - Chronic Diseases related to Aging and
Health Promotion and Disease Prevention (Adopted by the Committee on May 15, 2012
21
Linda Lee, MD, MCISc,ab Loretta M. Hillier, MA,cd Paul Stolee, PhD,e George Heckman, MD, MSc,fg
Lee L, Hillier LM, Stolee P, Heckman G, Gagnon M, McAiney CA, Harvey D. Enhancing Dementia Care:
A Primary Care–Based Memory Clinic. J Am Geriatr Soc. 2010 Nov;58(11):2197
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26 Champlain CVD Prevention Network, Atlas of Cardiovascular Health in the Champlain Region 2011
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EXPERT TASK GROUP RECOMMENDATIONS REPORT