Healthy Heart Society of British Columbia
Vancouver, British Columbia, Canada
Chris Rauscher, MD
Andy Ignaszewski, MD
Liza Kallstrom, MSc
Paddy O’Reilly, BA FSSE
Valerie Tregillus, RSA
Howard Platt, MD
Treena Chomik, PhD
Laurie Gould, MSA
Art Macgregor, MD
Connie Sixta, MBA
To increase the proportion of congestive heart failure (CHF) patients receiving optimum care according to evidence-based guidelines to 85 percent.
Patients will have left ventricular ejection fraction documented by ECHO or RNV [target = 85 percent]
Patients with documented systolic CHF will be on ACE-I (or ARB if intolerant) [target = 85 percent]
Patients with documented systolic CHF will be on B-blocker (or ARB if intolerant) [target = 85 percent]
Patients will have documented self-management goals, including daily weights [target = 85 percent]
Patients will have fewer readmissions to hospital [target = 50 percent decrease]
Implemented Patient Reminder sheet from clinical practice guidelines
Developed and implemented B-blocker titration protocol
Developed and implemented diuretic protocol
Provided Chronic Disease Management (CDM) Toolkit as a secure, online registry management tool to assist with registry development, data entry, guideline-based recall, and run chart reporting
Addressed privacy, security, and confidentiality concerns through a two-factor authentication model and role-based access permission (physicians can grant access to their patients to other members of the patient’s care team on an as-needed basis)
Tested multidisciplinary care approach, including Registered Nurse, Registered Dietitian/Nutritionist and Pharmacist
Tested a Shared Care arrangement between General Practitioners and Cardiologists
Developed a policy for reviewing echocardiograms via tele-health in rural communities
Implemented a new way of partnering, combining health and community, public and private, grass roots and more formal planning people, regulatory and professional bodies, funding agencies and practitioners into an effective collaborative (17 organizations represented on the Steering Committee)
Fostered new networks, particularly at the local primary care level for team development
Achieved limited and isolated success at a systems level to understand and implement shared care between primary care and specialist physicians
Summary of Results / Lessons Learned / Next Steps
Translating clinical practice guidelines for heart failure into a focused aim statement, measures and targets embedded in a flow sheet (encounter form) greatly helped to implement evidence-based practice. Decision-support tools and protocols were developed to support achieving the collaborative measures.
It is possible for primary care physician practices to deliver specialist-level of care for CHF patients, as demonstrated by the significant changes in the core process measures of drug utilization and self-management goal setting.
Information systems are a fundamental support for chronic disease management (CDM) and a necessary part of the redesign process. The CDM Toolkit supported the measurement, reporting, recall and planned care at this time, all facilitating change.
Engaging a registered nurse, internal or external to a physician practice, was of great benefit, although it took time to develop the working relationship.
Key to long-term success of CDM is self-management. Patients engaged in this process and wanted it. The use of Patient Reminder Sheet from the practice guidelines was felt to be very helpful. Many teams developed additional resources and tools to assist in implementing self-management practices.
Many partner organizations came together and formed new partnerships to ensure the successful outcome of the collaborative: no one organization was ‘in charge’; all came together because of a shared vision and a willingness to share accountability.
The Chronic Care Model proved to be very valuable as our systems framework for overall health systems transformation.
Clarifying confidentiality and privacy issues at the outset of the collaborative proved to be very helpful, and will be instrumental in future spread activities to new clinical and community settings.
Having some financial incentives was very helpful in brining physicians to the table initially; additional incentives will need to be developed and aligned with desired outcomes.
Group learning process for the practice teams is a good learning mechanism; mutual learning from peers enhances credibility of process.
Co-Director, CHF Collaborative
Healthy Heart Society of BC
[Storyboard presentation at IHI's National Forum, December 2004]