Canadian Heart Health Strategy and Action Plan CHHSAP The Need for System Change in Cardiovascular C

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Canadian Heart Health Strategy and Action Plan
(CHHS-AP) The Need for System Change in
Cardiovascular Care TWG-6 ReportEnsuring
Timely Access to Quality Chronic Disease
Management/Rehabilitation and End-of-Life Care
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Major Issues

• Chronic Disease Management
• Focus on acute care
• resources
• funding
• wait times
• Need for support at the primary care level
• education/training
• decision support
• IT
• personnel resources
• specialty services support

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Major Issues

• Chronic Disease Management
• Self-management support
• patient access to information
• behavior change
• psychosocial issues
• 4. Local buy-in

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Major Issues

• Cardiac Rehabilitation
• Access/supply issues
• Perception that cardiac rehabilitation is only
  for post-MI
• Cardiac rehabilitation not seen as a part of
  integrated cardiac care services

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Major Issues

• End-of-Life Planning and Care
• End-of-Life care as an afterthought emphasis on
  preserving life need for planning
• Prognostic uncertainty
• Knowledge gaps, lack of professional education

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Key Recommendations

• Chronic Disease Management
• Cardiovascular care delivery in Canada should be
  delivered in accordance with principles embodied
  in the Chronic Care Model (or one of its
  versions)
• Risk Factor Modification
• early risk identification
• stratification by risk
• Continuity of Ongoing Cardiac Care
• primacy of primary care team
• seamless transitions of care/integrated care
• information system support for care transitions

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Key Recommendations

• Chronic Disease Management
• 3. Responsive care
• appropriate provider
• patient centered care
• interdisciplinary teams
• meets local needs (Aboriginal/Indigenous)
• Ongoing evaluation of system performance
• monitoring of process and outcome indicators
• identify barriers

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Key Recommendations

• Cardiac Rehabilitation
• The Health System
• cardiac rehabilitation recognized as part of
  overall cardiovascular care
• services should be in accordance with Canadian
  Association of Cardiac Rehabilitation guidelines
• Coordinated Rehabilitation Care
• should follow CDM principles
• coordinated, sited in the community
• accessible to at-risk cardiovascular patients
• Special projects
• demonstration projects for innovation

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Key Recommendations

• End-of-Life Planning and Care
• Implement the 2006 CCS Recommendations
• (Consensus Conference on the Management of Heart
  Failure 2002 Canadian Consensus Report on the
  Care of the Elderly Patient with Carciovascular
  Disease)
• Implement Key Performance Indicators
• process indicators and data for decision making
• Enhance Health System Capacity
• training
• supports, resources

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Unique Aspects of Cross-Cutting Issues

• Reducing inequities
• CDM principles of adapting care to communities
• Community resources and other sources of Rehab
  provision
• Community resources for End-of-Life Planning and
  Care
• Expanding the Knowledge Base
• proliferation of CDM principles
• innovation sites for rehabilitation
• training, research in End-of-Life

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Unique Aspects of Cross-Cutting Issues

• Translating knowledge into action
• use of data to drive service delivery
• need for knowledge in Rehabilitation and
  End-of-Life
• Addressing impact/outcomes of interventions
• need for robust IT solutions EHRs, registries,
  linked databases
• Addressing Aboriginal/Indigenous CV health
• principles of CDM
• local solutions

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Other

• Linkages/overlap with other Themes
• Need for robust decision support, registries,
  EHRs, data for evaluation, surveillance
• Emphasis on prevention both primary and
  secondary, need for behavior change, keeping
  people healthy via all aspects of environment
• Some risk factors are chronic diseases (e.g.
  hypertension) prevents traditional
  cardiovascular disease

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Other

• Linkages/overlap with other Themes
• principles of CDM, adapting to local situations,
  using local resources
• transition in and out of acute care acute care
  providing support to primary/chronic care

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Discussion/Questions?
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TWG 6
primary care
case management
self management
patient
risk stratification high medium
low

• generic services
• behavior change
• exercise
• community
• self-management

• specialty services
• HF clinic
• rehab
• palliative
• geriatric
• home care

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Electronic Medical Records and Registries
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Patient Profile Viewer
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