By 2025, the Ted Rogers Centre for Heart Research will reduce re-hospitalizations for heart failure by 50 per cent while limiting length-of-stay in hospital. A team of cardiologists, primary care physicians, advanced care nurse specialists, pharmacists, dieticians, psychologists, physiotherapists, and information technology specialists have united to change how we manage heart failure.
Higher quality care
Understanding the journey of each heart failure patient is key to helping them avoid lengthy hospital stays. To do so, we will optimize guideline directed medical care, tighten the care a patient experiences from his or her medical team, and dissolve the significant issue of fragmented care. A model of care for heart failure means a comprehensive approach and seamless communication between all members.
The integrated program’s major investments in intermediate and transitional care have begun:
- Richard A.G. Robinson Heart Function Day Unit: This new specialized treatment space at UHN will provide short-term outpatient therapy, interventions and infusions. This way, patients can avoid be admitted to hospital.
- Rapid Ambulatory Program for Interventions and Diagnosis in Heart Failure (RAPID): For newly diagnosed, a RAPID heart failure clinic follows patients for up to a month after being discharged from the hospital or the emergency department, offering information, self-management support and medical care during the transition to a cardiologist or family doctor.
Both programs allow patients who need urgent attention to be seen quickly and treated as if they are inpatients – but in an outpatient setting.
Meanwhile, TRCHR nurse practitioner professors are in place to ensure that the integrated program is running as intended at clinical, education, and quality improvement levels. They represent the foundation of the smooth transition of patients with heart failure through the medical system.
The integrated program leans heavily on major technological advances. The Centre is transforming information, making EMRs work for both patient and health-care environment. An IT shift will enhance communication and deliver real-time metrics to track patient progress – then feeding that information back into each individual EMR.
The team is building a new remote patient monitoring tool called “Medly” that will permit doctors and nurses to monitor heart failure patients who are at home. This will benefit the delivery of health care while tapping into people’s capacity to care for themselves.