Comprehensive Program in Heart Function

By 2025, the Ted Rogers Centre for Heart Research aims to reduce re-hospitalizations for heart failure by 50 per cent while limiting length-of-stay in hospital. A team of cardiologists, primary care physicians, nurse practitioners, registered nurses, pharmacists, dieticians, psychologists, physiotherapists, and information technology specialists have united to pursue this ambitious goal.

In so doing, they will change how we manage heart failure here in Ontario, and share what we learn across the globe.

Higher Quality Care

By carefully understanding the journey of each heart failure patient, we can help avoid hospital stays – a critical aspect for both their quality of life and prognosis. A team based model of care for heart failure patients, means a comprehensive approach built on seamless communication between all members.

We began by investing in intermediate and transitional care, marked initially by two outpatient programs at the Peter Munk Cardiac Centre. A new heart function day unit offers outpatient therapy and interventions, helping patients avoid being admitted to hospital. Meanwhile, a nurse practitioner-led “RAPID” program carefully transitions heart failure patients from the emergency room or hospital ward to their family doctor, internist, or cardiologist.

A quality improvement (QI) program, led by a multi-disciplinary committee of practitioners, ensures high-quality care for patients with heart failure by performing novel studies on QI in heart failure care, scaling up successful QI interventions, and training the next generation of clinical leaders.

Digital Health Revolution

The Digital Health Program leverages state-of-the-art, home-based health and lifestyle monitoring technologies to improve patient self-care and provide early alerts of potential problems (to patients and health-care providers). This permits rapid intervention in order to prevent emergency department visits and hospitalizations.

Heart failure is a common cause of avoidable hospitalization. We have shown that telemonitoring of patients enhances self-care, which is shown to reduce hospitalization and improve quality of life. Telemonitoring empowers patients to track their vital signs and symptoms, and receive automated instruction and clinical intervention for alerts creating teachable moments. Clear actions are provided to the patient (when appropriate), and each patient can see cause and effect. The automated instructions are based on current physiological measurements, self-monitored symptoms, and readily analyzed trends in both. At the same time, automated real-time alerts and physiological data can support clinical decisions.

This digital shift comes courtesy of smart medical devices and home appliances that feed data back to a patient’s health-care team. These include the “Medly” remote patient monitoring platform and the CardioMEMS™ HF System, implanted in a patient’s pulmonary artery.

Meanwhile, the Computational Biomedicine and Clinical Mobility Program will incorporate patient data directly into updated electronic medical records at Peter Munk Cardiac Centre, so clinicians can deliver optimal care.

Ted Rogers Centre Professors in Nursing

Specialized heart failure nurse practitioners are critical team members. They ensure that the clinical, education, and quality improvement goals of the program are on target and that patients with heart failure transition smoothly through the medical system. Nurse practitioners help to provide continuity of care for patients and families between the inpatient and outpatient settings, and interact with allied health and community partners where appropriate.

Focusing on patient care, they lead the way in key areas including:

  • Advance care planning where patients face difficult treatment decisions, particularly at end-of-life. Using a variety of educational strategies, this program will help us understand the patient experience of advance care planning, and help us build the right tools to support them.
  • Frailty, a state of diminished physiologic reserve that makes a patient more vulnerable to adverse outcomes.
  • How health literacy contributes to a patient’s outcome and helping them develop the knowledge, skills and abilities to manage their heart failure effectively.
  • Educating patients and families on heart failure self-care with web-based resources (like the heart failure patient website).
  • Participating in the management and education of patients who are using remote monitoring systems such as Medly or CardioMEMS.