Integrated Clinical Pathways for COPD and CHF: Collaborative Approaches to Value-Based Care

Background: This presentation will outline the implementation and evaluation of two integrated clinical pathways (ICPs) for Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) within the Frontenac Lennox and Addington Ontario Health Team. The project aims to enhance care coordination, reduce hospital readmissions, and support community-based management for COPD and CHF patients, leveraging collaborative partnerships across primary, secondary, and community care settings through a hub-spoke-node model.

As chronic diseases contribute significantly to healthcare burden, integrated care pathways present a promising approach to optimize resources and improve patient outcomes. The development and deployment of ICPs for COPD and CHF patients is critical to enhancing value-based care, targeting efficiency, and improving patient access to necessary services while minimizing strain on emergency and acute care systems.

Approach, Methods and Partnerships: Key partnerships were established between local Hospitals, Community Health Centres, Home and Community Care, Community Paramedicine, Primary Care, Patient Advisors, and Best Care (ARGI) Certified Integrated Disease Management Clinicians. Each partner brings unique expertise and resources, creating a network that enables efficient referrals, specialized outpatient services, and remote patient monitoring. Centralized Project Management and data supports were crucial to the success and coordination of this work.

Activities include:

•Embedding Best Care Clinicians in Primary Care Health Homes to streamline COPD/CHF patient management and education.

•Developing a resource inventory and pathway guiding documents to support navigation for Primary Care.

•Implementing community paramedic support for home management of decompensating CHF/COPD patients.

•Developing hospital-community protocols to reduce emergency department admissions and establishing rapid access clinics for follow-up.

•Utilizing remote patient monitoring to improve discharge planning and follow-up for high-risk patients and establishing coordinated escalation and de-escalation of patients between home and nodes.

Milestones:

•Sept 2024: Optimize outpatient care for CHF/COPD patients through case identification, guideline-directed medical therapy (GDMT) usage, and discharge planning.

•Oct 2024: Pilot of Best Care Certified Integrated Disease Management Clinicians across seven Primary Care Health Homes in the region.

•Dec 2024: Improve transitions of care and post-discharge follow-up, with high-risk patients enrolled in remote monitoring via Ontario Health at Home.

•Mar 2025: Establish admission protocols in emergency departments and track patient management to ensure comprehensive care.

•Apr 2025: Roll out community paramedic support to maintain patients at home and mitigate hospital readmissions.

Results (Expected): The ICP initiative is projected to decrease hospital admissions, improve patient satisfaction, and foster timely access to specialized care. Additionally, through education and protocols, primary care providers can confidently navigate regional systems to provide quality care aligned with ministry standards. Injecting chronic disease resources at the primary care level is expected to improve downstream prevention and early intervention without adding provider burden.

Implications: This collaborative approach demonstrates a sustainable and scalable model for integrated care, aligning with value-based health goals through optimized resource allocation and patient-centered practices. By fostering partnerships among healthcare providers, this initiative offers insights into structuring ICPs that serve a broad, diverse population, including priority groups like older adults, Indigenous people, and the unattached.