PIONEERING HEART FAILURE CARE
IN THE COMMUNITY
NP Forum for Nursing and Allied Health
University of Alberta Hospital
April 10, 2015
L li Ch
Leslie
Chrysanthou
th RN
RN, BN
Nurse Clinician
IHC Heart Failure Team
Calgary Zone
Th Bi
The
Birth
th off a HF Team
T
In 2011 heart failure was identified as one of the top three
reasons that AHS-Calgary Zone Home Care clients
utilized emergency departments (ED) and acute care.
The IHC Heart Failure Team was launched in April 2011
with funding designated for 3 RNs to develop &
implement the team.
Goals of the teams were to reduce ED utilization, hospital
admissions and length of stay in Acute Care.
This team is the first of it’s kind in Canada.
2
HF Team Program Design
The p
program
g
was designed
g
byy tailoring
g the existing
g Home Care
Case Management Model to incorporate the model of care
utilized in the Calgary Zone Heart Function Clinics.
This amalgamation was aimed at:
• providing specialized case management of complex home
care HF clients including advanced clinical education in the
managementt off heart
h t failure
f il
• developing strategies for fostering relationships with health
care partners
• defining the HF home care team mission statement
• developing admission criteria
• mapping
i the
th care process
3
Program Evaluation Indicators
•
•
•
•
•
Total number of clients
Total number of new clients
Average number of clients per caseload
Number of emergency department visits
Number of acute care admissions
4
Initial Success
After a six month evaluation of the program the team
expanded to include a Nurse Clinician,
Clinician a total of 7 RNs
RNs,
a Physiotherapist and a Care Manager.
One of the first tasks the team took on was to develop a
model of care for the HF home care client. This model
outlined the mission statement, referral process,
admission criteria,, case management,
g
, visit follow up,
p,
communication with health care partners, discharge or
transfer to other teams.
5
HF Team Mission Statement
To provide focused, interdisciplinary
management of Integrated Home Care (IHC)
clients living with heart failure through
comprehensive assessment, care planning and
education aimed at optimizing the client’s quality
of life and safe living in the community
community.
6
HF Team
T
Goals
G l
• To decrease ED visits & hospital admissions related to HF
exacerbation.
• To p
provide client & family
y education regarding
g
g HF
self monitoring & self management.
• To facilitate the efficient and cost effective use of
community
it resources in
i th
the managementt off heart
h t
failure.
• To provide HF expertise & resources to support IHC
professionals, clients & their support systems.
• To collaborate with other health care professionals &
community agencies to provide a continuum of care.
7
Admission Criteria
• Client meets the criteria for admission to home care.
• A primary diagnosis of HF and one or more admissions
t acute
to
t care in
i the
th last
l t year for
f HF or att the
th requestt off
the cardiac function clinic.
• Clients and/or family are teachable and willing to accept
the interventions provided by the HF team.
• It is expected that the involvement of the HF team will
make
k a positive
i i iimpact on client
li
outcomes.
8
Referral to the HF Team
Referrals come from:
• Hospital via transition services
• GP or Cardiologist
• Cardiac Function Clinics
• Other Home Care Teams
9
RN Case Management
g
• Follow the Canadian Cardiovascular Society guidelines for HF
management.
• Complete full cardiac assessments and monitor medication
titration, standing orders, lab work and diagnostics.
• Assess teaching needs and provide ongoing
client/family education.
education
• Communicate and collaborate with client’s Family Physician,
Cardiologist, Cardiac Function Clinics.
• Consult other IHC Health Care professionals
(OT/Pharmacist/Dietician/Palliative care/Geriatric Consult Team)
p
y clinics.
as well as to external specialty
10
Client Self-management Strategies
•
•
•
•
•
•
•
•
Understand diagnosis & treatments
Medication teaching & review
Self monitoring of signs & symptoms
Dailyy weights
g
Symptom management & control strategies
Sodium & fluid restriction
Energy conservation
Lifestyle management
11
Nurse Clinician
• Supports advanced HF education for the HF Team &
frontline IHC Case Managers,
g , following
g Canadian
Cardiovascular guidelines and best practice guidelines.
• Develops & facilitates partnerships within and outside of
the IHC Program.
• Supports education of partners about the role and
opportunities within the HF team
team.
• Client consultant
12
HF Team Physiotherapist
• Advanced cardio-respiratory assessment
• Focus on improving/maintaining functional mobility &
ADL’s
ADL
s related to improved quality of life
• Develop a cardiac rehab focused exercise program &
energy conservation strategies
• Partner with Cardiac Wellness programs & Cardiac
Function Clinics
• Access Therapy Assistant for delivery of intervention
strategies for the HF client
13
HF Team
T
and
d Partners
P t
•
•
•
•
•
Client & Family
HF Case Manager
HF Ph
Physiotherapist
i th
i t
HF Care Manager
N
Nurse
Cli
Clinician
i i
•
•
•
•
•
•
•
Family
F
il D
Doctor
t
Cardiologist
Heart Function Clinics
Pharmacist
Dietician
Palliative Care Team
Other Home Care
Teams
• Community
y Paramedics
14
Ke Outcomes
Key
O tcomes
• 70% decrease in ED visits 3 months post referral to HF team.
• 41% decrease in ED visits 6 months post referral to HF team.
• 83% decrease in acute care admissions 3 months post referral
to HF team.
• 59% decrease in acute care admissions 6 months post referral
t HF team.
to
t
• Clients surveyed indicate an improvement in knowledge
regarding
g
g self management
g
and QOL
• Staff surveyed indicate improved knowledge,
clinical support and job satisfaction.
15
HF Team Stats April – June 2013
Emergency Rooms
Visits Post Referral to
the HF Team
Acute Care
Admissions Post
Referral to the HF Team
16
What’s Ne
Nextt
• Creating a process for care of the palliative HF client
• Collaborating with Palliative Care and Dr. Slawnych to
participate in end stage HF rounds
• Creating an IHC Practice Guideline for Heart Failure
Management
17