Success in Action: Cardiovascular Care

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Success in Action Cardiovascular Care

• HEART FUNCTION CLINIC
• THE CENTRE FOR FAMILY MEDICINE FHT
• WATERLOO REGION, ONTARIO
• Joseph Lee MD, CCFP, FCFP, MClSc
• Chair and Lead Physician

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OVERVIEW

• The CFFM Family Health Team
• Congestive Heart Failure
• Heart Function Clinic
• Goals, Roles, and Responsibilities
• Potential Pitfalls and Success Strategies

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The CFFM Family Health Team

• Inter-professional team
• 20,000 patients
• 4 sites in Waterloo Region
• Teaching affiliations with McMaster Family
  Medicine, UWO Family Medicine, UW Pharmacy, UW
  Optometry, WLU Social Work

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The CFFM Family Health Team
University of Waterloo Downtown Kitchener Campus
Health Sciences

• A - Under Development
• School of Pharmacy
• Michael G. DeGroote
• School of Medicine
• Waterloo-Wellington Campus
• Integrated Primary Health Care Clinic
• B Future Campus Development

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CONGESTIVE HEART FAILURE

• 1 at age 50, 5 at age 75, 25 at age 85
• Common cause of hospital admission
• Major factor lack of adherence to therapy
• High mortality rates

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CONGESTIVE HEART FAILURE

• MANAGEMENT
• Diet, lifestyle management
• Control underlying diseases such as DM, HTN, ASHD
• Medication diuretics, ACEIs, beta-blockers,
  others

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HEART FUNCTION CLINIC

• New initative
• Registry
• Team physician, pharmacist, nurse, dietitian
• Clinic supplements usual care of family physician

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HEART FUNCTION CLINIC

• EHR Template
• Diet, lifestyle, patient self-management goals
• Flu, pneumovax
• Tests Echo, ECG, CXR, Bloodwork
• Physical exam, weight
• Medication considerations Diuretics, ACEIs,
  Beta-blockers, ASA, etc.

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HEART FUNCTION CLINIC

• 2 alternating clinics q3-6 months
• Physician-nurse assessment
• Pharmacist-nurse-dietitian assessment
• Regular family physician /- cardiologist
  appointments continue

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GOALS

• Promote lifestyle management and self-care
• Improve adherence to medical management
• Complete annual CHF best practice template
• Further linkages with other CDPM programs such as
  HTN, DM, Memory Clinic, Mental Health,
  Anti-coagulation

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ROLES AND RESPONSIBILITIES

• Regular Physician diagnosis, refer into
  registry
• Clinic Physician review and order tests,
  optimize medical management
• Nurse patient education, coordinate tests and
  results, systems navigation

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ROLES AND RESPONSIBILITIES

• Pharmacist review and adjust medications,
  optimize medical management and adherence
• Dietitian review diet and lifestyle factors
• Nurse patient education, coordinate tests and
  results

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POTENTIAL PITFALLS SUCCESS STRATEGIES

• Poor communication
• Undefined roles
• Lack of team cohesion
• Underestimating development work

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POTENTIAL PITFALLS SUCCESS STRATEGIES

• Poor communication
• Strategies
• Regular, effective meetings
• Shared electronic health records
• Face-to-face, e-mail, informal

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POTENTIAL PITFALLS SUCCESS STRATEGIES

• Undefined roles
• Strategies
• Meetings to understand scopes of practice
• Use of medical directives where appropriate

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POTENTIAL PITFALLS SUCCESS STRATEGIES

• Lack of team cohesion
• Strategies
• Instill a sense of common purpose and vision
• Team Days
• Acknowledgement, rewards, and recognition
• Community charity events

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POTENTIAL PITFALLS SUCCESS STRATEGIES

• Underestimating development work
• Strategies
• Schedule administrative and meeting time
• Distribute tasks and leadership roles
• Physician buy-in
• Anticipate inter-professional learners

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SUMMARY

• Congestive Heart Failure high morbidity,
  mortality, and system cost
• CFFM Heart Function Clinic inter-professional
  team with pharmacist, physician, nurse, dietitian
  team
• Define Goals, Roles, and Responsibilities
• Communicate and have fun!