Focus on Heart Failure: Strengthening the Network of Care

June 8, 2015

Just as it takes a village to raise a child, it takes the efforts of many to maintain the health and quality of life of a person with heart failure. Cardiovascular specialists are essential, but no less so are the family doctors and other health care providers who deliver ongoing care; friends and family who provide daily support; and the patients themselves who must take an active role in managing their own health.

Mielniczuk, Lisa Marie
Lisa Mielniczuk, MD

Supporting, engaging and informing this network of care is central to successful chronic heart failure care. The University of Ottawa Heart Institute has been rolling out a series of initiatives to do just that throughout Eastern Ontario. These initiatives are part of an innovative Regional Integrated Heart Failure Strategy, funded by the Champlain Local Health Integration Network, and intended to ensure continuity of care, as well as a better quality of care and quality of life for heart failure patients, while reducing hospital readmissions, which will conserve limited health care resources.

The province has made addressing heart failure a priority throughout Ontario. But the Heart Institute strategy is unique in its focus on linking and supporting all those involved with heart failure, said cardiologist Lisa Mielniczuk, MD, Director of the Heart Failure Program. It is a key part of the Heart Institute’s commitment to walking with patients “every step of their heart failure journeys.”

Helping Patients Manage Their Own Health

“Living well with heart failure isn’t easy. It requires lifestyle changes and adherence to a routine of tracking key indicators, such as body weight,” stressed Program Supervisor Bonnie Quinlan, cardiology advanced practice nurse. Some of the most important lifestyle changes happen around diet, specifically reducing both sodium and fluids. While these changes may not sound like much, they can mean changing the habits of a lifetime, and that’s no small task.

Several of the initiatives under the heart failure strategy involve educating patients and providing them with the tangible support they need to make those changes. Registered nurse Amy Charlebois is the Transitional Care Navigator for patients being discharged from the Heart Institute, whether they go back home, to a long-term care facility or to another hospital. Charlebois makes sure patients are discharged with everything they need, including follow-up appointments. If a patient doesn’t have a family physician, she will help find one. She communicates with the pharmacy to ensure there are no medication conflicts, and that the patient knows what to do once at home. She provides patients with daily weight trackers, which lets them know when to call their doctors or go to the emergency department. 

“I wrap up loose ends and help expedite things to facilitate a smooth discharge,” Charlebois said of her role. “I work with our staff on the units and we make sure there’s nothing that’s been missed. We have amazing nurses who start heart failure education at the point of admission. Each patient is an individual, with different needs, so it’s a patient-tailored experience.”

Norvinda Rodger (left) and Amy Charlebois, RN

Patients also know they’re not alone once they leave the hospital. Most are followed through either the interactive voice response system or, for higher-risk patients, the Telehome Monitoring program (see “Telehome Monitoring Helps Patients Help Themselves”).

For everyone except the telehome monitoring patients, who are already speaking with a nurse regularly, Charlebois calls within 24 to 72 hours of their arriving home to check that everything is going smoothly.

“We go over medications, the importance of heart failure self-management strategies, sodium and fluid restrictions, signs and symptoms of heart failure, and when to call the doctor,” she said.

If a patient is transferred to another hospital, Charlebois will work with that hospital to make sure it has all the information it needs and that patients are on a heart failure diet and being weighed daily—important details that are crucial to successful heart failure management.

Patients can contact a heart failure nurse if they have any questions or concerns. “Patients love the support they receive,” said Quinlan.

Support for Primary Care Physicians

We ask a lot of primary care physicians. They are the first ones to see patients suffering from heart failure, which can be difficult to diagnose, and they manage these patients’ care in the community. If their patients are hospitalized at some point, they resume responsibility for the care of those patients afterward. And because the Heart Institute serves all of Eastern Ontario, physicians are often far from the facility’s specialists and resources.

The Regional Integrated Heart Failure Strategy is intended to provide primary care providers with the support they need to deliver high-quality care. And it began by asking these physicians what they felt they needed.

Supporting, engaging and informing the network of care is central to successful chronic heart failure management.

“We don’t do these things in isolation. We wanted to make sure the strategy was going to meet physicians’ needs,” said Heart Failure Strategy project lead Norvinda Rodger. “Collaboration in these initiatives is key to success.”

Input from doctors helped identify two key areas where support was needed: learning more about heart failure and caring for their heart failure patients. Under the strategy, educational support now comes in several forms:

  • The Champlain Primary Care Cardiovascular Disease Prevention and Management Guideline, a reference publication targeting the primary care community that covers all cardiovascular disease, including heart failure
  • A heart failure continuing medical education (CME) unit, delivered through the Canadian Medical Association
  • An online Heart Failure Resource Centre for professionals (in development), which will include information about services at the Heart Institute; clinical practice guidelines to help with diagnosing, classifying and managing heart failure; professional education materials; information on research and other projects under way at the Heart Institute; and links to other organizations involved in heart failure, such as the Canadian Heart Failure Network

To make the transition in care from the hospital back to the community truly seamless, the Heart Institute developed a comprehensive discharge summary to better support primary care providers. The most important part of the package is a standardized discharge summary that includes key information about treatment received, medications and other specifics. The physician receives a one-page “Top 10 Tips for Heart Failure Management” and access to a heart failure nurse specialist, if the doctor needs any additional information.

“These tools were developed based on consultation with primary care physicians,” said Rodger. “Physicians who were surveyed post-implementation told us they really appreciate the comprehensiveness and support.”

Working with primary care physicians is “a big part of heart failure management,” said Dr. Mielniczuk. “This is key to the success of the regional strategy.”

Keeping Patients Out of the Hospital

While many of these initiatives are intended to help heart failure patients after they have been hospitalized, keeping them out of the hospital in the first place is a priority.
Heart Institute cardiologists can now refer heart failure patients in need of immediate assistance, often due to fluid overload, to the Rapid Intervention Clinic. There, needed medications can be provided intravenously on an outpatient basis. Before this clinic existed, the only option was to have the patient sent to the emergency department or, in some cases, directly admitted to the hospital.

An added benefit, said Charlebois, who sees patients in the Rapid Intervention Clinic, is the opportunity to provide patients with the same transitional care that inpatients receive. Treating individuals on an outpatient basis also eases demands on the resources of the Heart Institute and saves the health system money.

For patients who live outside of Ottawa, the Heart Institute is in the process of establishing regional heart function clinics at local hospitals or other facilities, to reduce the travel required to visit a heart failure specialist. These clinics are intended to supplement telemedicine, through which patients are seen at the Heart Institute by video link.