Abstract
Background: Heart failure is a major public health concern impacting millions of people globally. The Huron Perth and Area Ontario Health Team (HPA-OHT), located in southwestern Ontario, is challenged with an aging demographic, strained health human resources, rural geography, and patients with increasingly complex chronic health conditions. Patients with heart failure have been identified as a priority population with opportunities to improve care integration and involve patients as partners in their care. The number of individuals in Huron Perth that have heart failure is growing with the increasing average age of our citizens. Patients with heart failure are cared for by many sectors throughout their patient journey making integration an opportunity to improve access and care quality.
Approach: In 202, the Huron Perth and Area Ontario Health Team identified the need for an integrated, optimized and people-centred heart failure treatment model to better serve patients living with heart failure. To achieve this, the HPA-OHT collaborated with member organizations, the HPA-OHT Heart Failure Working Group, Patient and Family Advisors and Middlesex London OHT to implement the Spoke-Hub-Node (SHN) model of integrated care for heart failure. The SHN model is a community-initiated integrated disease management structure in primary care practices that standardizes connections to an established network of community care partners and ensures that a streamlined navigation process for accessing specialist support exists. At the heart of our program are our spoke Primary Care teams, with the central hub being our Internal Medicine team based in Stratford and connecting to London Cardiac Care as a vital node. This model has provided the opportunity to transform healthcare access and break down barriers commonly seen between Primary Care and Specialist Care sectors.
Results: Over the past four years, there has been a notable trend in heart failure admissions and emergency department visits within our healthcare system. Specifically, the number of heart failure admissions per 00 patients has decreased from 8.6 in 209/20 to 6.8 in 2022/23, marking a reduction of .8 admissions per 00 patients. Similarly, the rate of heart failure-related emergency department visits per 00 patients has seen a decline from .6 in 209/20 to 9.2 in 2022/23, indicating a decrease of 2.4 visits per 00 patients. The 30-day readmission rates for heart failure patients, both for all causes and specifically heart failure-related causes, have shown improvement. The overall 30-day readmission rate has decreased from 20% in 209/20 to 3% in 2022/23, while the readmission rate specifically for heart failure causes has decreased from 8% to 7% during the same period. Additionally, there has been a shift in the allocation of home and community support services, with a decrease from 3500 hours in 209/20 to 2000 hours of personal support services in 2023/24. The integration of primary care teams supporting the heart failure program has increased, with the number of teams with nurse practitioner support rising from 0 in 209/20 to 5 in 2023/24. Finally, the provision of care by Best Care Case managers, specifically respiratory therapists, to heart failure patients has expanded significantly, from 0 therapists in 209/20 to 7 therapists across 9 Family Health Teams and 2 Family Health Organizations in 2023/24.
Implications: The Spoke-Hub-Node model of integrated heart failure care within the HPA-OHT has streamlined care for patients while improving access and flow to heart failure services within Huron and Perth. The focus on education and knowledge for providers and patients is improving the overall quality of care. Next steps are to continue with evaluating impact and sustainability planning. This commitment to ongoing assessment and improvement will help to ensure that patients continue to receive high-quality heart failure care.