ACAC Symposium April 14th, 2008: Chinook Health 11 Improving Access to Heart Failure Services in Chinook Health Building the Heart Failure Network ACAC.

ACAC Symposium April 14th, 2008: Chinook Health

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Improving Access to Heart Failure Services in Chinook Health

Building the Heart Failure Network

ACAC Symposium April 14th, 2008: Chinook [email protected]@chr.ab.ca

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Today….

The issue

Where we are

Where we want to go

How ACAC is helping us get there

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The Issue

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Chinook Heart Function Clinic

Physician directed, nurse-managed clinic established in 2001, offering:

Expert assessment and follow up A customized, evidence-based treatment plan Education and self-management strategies and

support Support and connections to community resources

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Good News…andBad News

We are providing quality care and achieving good outcomes in the HFC but….

Seen in Heart FunctionSpecialty Clinic

Heart Failure Population in

Chinook

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We know that many patients struggle with HF management…

Many patients visit the ER, are treated for HF and discharged

Many patients are admitted to acute care facilities for exacerbations of heart failure

Many patients struggle in the community with frequent episodes of instability

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Increasing our Reach

We seek to create a network of health care providers across the continuum of care who are informed and committed to providing comprehensive, evidence-based heart failure care.

The Heart Failure Network

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HFN: Two Phases

Phase 1: Urban

Lethbridge and immediate area

There are a number of gaps

Centralizes our initial efforts in one venue

Phase 2: Rural

Interdisciplinary primary care teams generally more established

Communication strengths between health care providers/agencies in smaller locales

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The Heart Failure Network (HFN)…

offers navigational support and centralized access to information and resources for patients, families and health care providers living with and caring for chronic heart failure.

focuses on improving the lifestyle of heart failure patients

creates connections between clients and available community resources.

builds on existing strengths to improve heart failure care in Chinook.

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The Patient Journey: HFN

3 Visits: Initial

Within 7-14 days of discharge (or referral from community)

Visit # 2 Within 30 days of discharge/referral Heart Failure Education Class

Visit # 3 Within 30-60 days of discharge/referral

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Currently…

Comprehensive Communication Plan Internal/external audiences

Identifying and addressing policy gaps Referral processes Physician orders/evidence-informed care

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Currently…

First patients seen April 1!