Cardiac Rehab and Primary Care: Avoiding Losses in Care Transitions. Neville Suskin Heart & Stroke Clinical Update 2012

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1 Cardiac Rehab and Primary Care: Avoiding Losses in Care Transitions Neville Suskin Heart & Stroke Clinical Update

2 Disclosure Med. Director SJHC CR Co-principal of Lawson e-cr application LCVIS SJHC CR received support from:astra, BMS-SA, Pfizer, Merck, Servier 2

3 Session Plan Presentation. 30 min Small group break-out. 30 min Wrap-up 20 min 3

4 Objectives Review paradigm that Cardiac Rehab is exemplar of chronic cardiovascular disease management Review impact managed transitions care Review evidence of information sharing preferences between cardiac rehab and primary care. Establish prototype for patient centered Cardiac Rehab and primary care. 4

5 Audience Composition OBJECTIVES Review audience composition: MDs vs. non MDs PCPs vs. non PCPs EMR vs. non-emr Single vs. group Type Prof Type Prof EMR Group MDs PCPs Yes Yes Non MDs Non PCPs No No 5

6 CR as Chronic Disease Management (CV-CDM) Inter-disciplinary, case management model using theoretically-informed & evidence-based approach to behavioural change, unique in CDM exercise, dietary, smoking, psychological health secondary prevention medications & adherence patient self-management Arthur, Suskinet al,cjc

7 Ontario s Chronic Disease & Prevention Framework Target Building the Case for Change. Preventing and Managing Chronic Illness Presentation to the South West LHIN Board of Directors June 25,

8 CR & Primary Care Chronic disease management in CR should be delivered by adhering to the notion of shared care between the primary care team and regional CR program, depending on the patient s risk for future events. Cardiac rehabilitation delivery must be truly patient-centered and primary care based for the majority of patients. Case managementfor higher risk, more complex patients. Resource person or patient navigator on the primary care team may facilitate access to services for patients. Regional CR facilities should serve as resource centresfor the primary care-based CR centres. Flexible delivery system to allow care close to home Use of novel telecommunications technology Communication between the regional CR team and the primary care team is very important Arthur, Suskinet al,cjc

9 Continuity of care Multidisciplinary management Informational use of information from previous events to make patient care appropriate, linking health care providers Management provision of complementary services within a shared management plan Relational the ongoing relationship between a patient and one or more health care providers, providing a link in care. Haggerty et al. Continuity of care: A multidisciplinary review. BMJ 2003;327:

10 1 0

11 PCPs & Guideline Overload 65% PCP day req dfor comprehensive guideline review 5 Chronic Diseases Lewanczuk, CJC, June 2009

12 Get with the Guidelines Best Practices for Acute Coronary Syndrome (ACS-GAP) Coordinated Patient- Focused Care Smoking cessation follow-up counselling arranged Evidence-based secondary prevention medications prescribed Systematic liaised inpatient CR referral Patients attached to appropriate postdischarge diabetes community care Signed by patient and RN Physician follow-up

13 Mortality pre-post ACS-GAP % Mortality Hospital 30 Day 1 Year Before After GAP Eagle et al. JACC. 2005;46:

14 HF Checklist Impact 90% 80% 83% 70% 60% 50% 40% 30% 20% 10% 0% 48% 44% 42% 20% 23% 8% 2% ACE/ARB IncrBB/ACE 30 D Hosp 6 M Hosp Control Checklist Basoor A, HF Checklist, ACC 2012

15 Hernandez et al

16 ACS -Systematic Smoking Cessation

17 Case 1 50 yrwomen, accountant (works from home), smoker, bmi24; WC 98 cm, TC 6, LDL 4, HDL 1, TG 2.2, fbg8.5, BP160/80; lives 1 km from CR site & YMCA Depressed & anxious ACS -STEMI Single vessel LAD PCI, Normal LVEF 10 min Bruce, no angina, no ST shift 17

18 Case 2 50 yr women, accountant (works from home), nonsmoker; BP 120/80; bmi30; WC 100cm, TC 6, HDL 1, LDL 4, TG 2.2, fbg4.0, creatinine150 umol/l, lives 1 km from CR site & YMCA ACS Diffuse 3 vessel disease, no easy targets LVEF = 30-40% Mild HF 5 min Bruce, 1mm ST shift, limiting angina, frequent non-sustained VT 18

19 Cases Follow-up Key information transfer elements CR - exercise Location Strategy Psycho-social issues Pharmacotherapy Lifestyle 19

20 Patient Handovers to Primary Care Decrease re-hospitalization Medication reconciliation Electronic tools to facilitate: Quick and structured summary generation Discharge planning Shared involvement in follow-up by hospital and PCs Electronic discharge notifications Web-based access to discharge information Improving Patient Handovers From Hospital to Primary Care A Systematic Review: GijsHesselink et al, Ann Intern Med. 2012;157:

21 Continuity of CR care to Primary Care OBJECTIVES To identify and describe utility information that is transferred from CR programs to primary care physicians RESULTS: 89 primary care MDs approached, 50 participated (62%) 42% received the CR discharge summary Great variability in clinical and service data reported 52% reporting an exercise prescription for the home or community 42.0% reporting medications prescribed Four themes requiring improvement were generated Patient behavioral management issues Health system factors Efficiency of data transfer Communication issues DL Riley et al. A mixed methods study of continuity of care from CR to PCPs. CJC 2009;25(6):e187-e

22 DL Riley et al. A mixed methods study of continuity of care from CR to PCPs. CJC 2009;25(6):e187-e192.

23 Prim Care Prov. perceptions ofcr Intake Record & Transmission 144 PCPs from 8 Ontario CR programs incl. 66 structured interviews: Improved Mx Fax Mode Strong agreement (4.3/7) that CR transition record met needs for care Intake LTR Useful 88 CR Intake LTR 48 Yee et al. BMC Health Services Research 2011, 11:231

24 CR Intake Summary Data Elements ratings point Likert Scale Yee et al. BMC Health Services Research 2011, 11:231

25 Quality CR Intake Summary All Info High Qual Satisfied Length OK Summ wld incr CR Ref 5 point Likert Yee et al. BMC Health Services Research 2011, 11:231

26 PCPs & CR Discharge Summaries 577 PCPs with patients at 8 Ontario CR programs CR D/C Summaries tracked from the CR to PCP s office. 139 (24%) PCPs participated: 99% PCPs were MDs F > M More recent grads 115 ptsper week 42% FHT Polyzotis et al, in-press Circ CV Qual& Outcomes

27 CR Discharge Summary Preferences D/C Summ Received D/C Preferred Fax Mail Percent Polyzotis et al, in-press Circ CV Qual& Outcomes

28 CR Discharge Summary Preferences Length Used for Pt Care Shared Pt Care All Necess Info Polyzotis et al, in-press Circ CV Qual& Outcomes

29 CR Discharge Content Preferences NYHA/CCS Risk Factors Meds Ex Test Intake vs. Disch Risk 4.43 Pt Care Plan Polyzotis et al, in-press Circ CV Qual& Outcomes

30 Your Experience yes no 10 0 CR D/C Summ CR Intake Summ CR Discharge Summ 30

31 Continuity of CR care to PCP:? Most important Component Diagnosis NYHA/CCS Risk Profile Meds Ex Capacity Ex Prescription Most Important 31

32 Outcomes Display Below Target Exceeds target 3 2

33 Composite Display QI Surveillance YES? 6 No? YES 33 No

34 CR Framework Care plan Case Finding: ACS AF HF TIA Best Practice Care Harmonized Guidelines Focused Quality Indicators Primary Care + Specialty Clinics where needed Web-based Quality Indicator Surveillance & Adherence Linkage to hospital EPRs and Registries

35 Thank you? s

36 Smoking cessation follow-up support initiated In-patient Care: Get with the Guidelines Best Practices for Acute Coronary Syndrome Referral to Cardiac Rehab Discharge Contract Diabetes Care Coordination Referral to Primary Care Out-Patient Care: Cardiac Rehabilitation & Secondary Prevention Program Progress report re C-V targets Risk factor summary Discharge Summary Care plan Primary Care: Long-term Follow-up Engaged, proactive SYSTEM of care providing an integrated, patient-centred continuum of quality health services

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