Specialist Collaborative Models RGPs of Ontario Ottawa - - PowerPoint PPT Presentation

Optimizing Outcomes For Frail High Risk Seniors Through Specialist-Specialist and Primary Care- Specialist Collaborative Models

RGPs of Ontario

Ottawa Transcatheter Aortic Valve Insertion (TAVI) program (Presentation 1)

• Dr. Allen Huang

The Ottawa Hospital RGPs of Ontario

 Since 2007, funding for 90 TAVIs/year  Weekly standing committee meetings  Members

• Interventional cardiology (4)
• Cardiac surgery (4)
• Radiology (TAVI – CT, Cardiac cath, echo)
• Geriatric

riatric medi dicin cine (since ince 2014 14)

• Nurse program manager
• Nursing
• Cath lab manager
• OR manager
• Anesthesia

 43 meetings  163 cases presented  103 accepted (20 SAVR, 25 medical /palliative, 3

not severe AS, 7 deaths, 5 misc)

 Average wait time 45-days  Mortality

• Waitlist 3
• Procedure 2
• 30-day 0
• 1-year 8

 Geriatrics consulted on 12 cases

• Pre-op (9) Recommended NO (4) 2 died within 3-months
• Post-op (3)

S W O T

Who Is Involved

WEAKN KNESS ESSES ES

• Only cardiology/

cardiac surgery fellows attend (ad hoc) STR TRENGTHS THS

• Multiprofessional
• Multidisciplinary
• Single program RN
• Great documentation

TH THRE REATS TS

• Single Geriatrician
• Single program nurse

OP OPPOR PORTU TUNITI NITIES ES

• Engage other residents
• Train other RNs

S W O T

Funding Sustainability

WEAKN KNESS ESSES ES

• funding cap – 90

cases/year

• No surge capacity

STR TRENGTHS THS

• Clinical outcomes

excellent compared to Canadian peers TH THRE REATS TS

• Changing indications
• Changing technologies
• Volume outstrips

resources

• New MOH funding

model implications OP OPPOR PORTU TUNITI NITIES ES

• Frailty assessment can

improve targeting and sharpen the model

S W O T

Policy Support

WEAKN KNESS ESSES ES

• lack of policy
• Service line response

to funding pressures STR TRENGTHS THS

• Heart Institute has a

strong regional and national recognition

• Clinical and research

programs TH THRE REATS TS

• elder care is not part
• f the Heart Institute

strategic plan OP OPPOR PORTU TUNITI NITIES ES

• opportunity for other

Canadian TAVI programs to learn

S W O T

Setting

WEAKN KNESS ESSES ES

• Single organ thinking

STR TRENGTHS THS

• Heart Institute has a

global reputation TH THRE REATS TS

• TAVI becomes a

standard user-selectable intervention OP OPPOR PORTU TUNITI NITIES ES

• Integration of the

geriatric approach

• TAVI program can

inform other heart programs

S W O T

Decision- Making

WEAKN KNESS ESSES ES

• Intervention biases
• Referral bias
• System bias for fixable

things STR TRENGTHS THS

• Flexible consultations
• Real-time shared

problem-solving TH THRE REATS TS

• Unsustainable volume
• Pre-referral priming

OP OPPOR PORTU TUNITI NITIES ES

• Share Canadian data
• Embed frailty

assessments

S W O T

Geriatrician Selection

WEAKN KNESS ESSES ES

• Single geriatrician

STR TRENGTHS THS

• Single geriatrician

TH THRE REATS TS

• Single geriatrician

competing interests OP OPPOR PORTU TUNITI NITIES ES

• Recruit new

geriatricians

S W O T

Patient Selection

WEAKN KNESS ESSES ES

• Frailty is difficult to

easily define

• Missing components

to STS risk score

• Waitlist management

STR TRENGTHS THS

• Society of Thoracic

Surgeons (STS) risk score is widely used TH THRE REATS TS

• Unrealistic expectations

& inappropriate referrals OP OPPOR PORTU TUNITI NITIES ES

• Results of McGill

multi-center TAVI- frailty study pending

S W O T

AGS Person-Centered Care

WEAKN KNESS ESSES ES

• Single RN
• Education

component limited to procedure & processes STR TRENGTHS THS

• Single RN contact
• Co-ordinates
• Disseminates
• Dedicated to program

quality and education TH THRE REATS TS

• Funding driven only

by volumes OP OPPOR PORTU TUNITI NITIES ES

• integrate patient

reported outcomes

• Patient decision aid
• Post-op delirium

management

 Goal of heart teams is the provision of patient-centred

care using a shared decision-making approach.

 Outcomes - consistent provision of guideline-based

decision making, better coordination of treatment plans, effective use of resources, and, for clinicians, greater knowledge and improved workplace satisfaction.

 The success … depends largely on collaboration amongst

multiple disciplines each of whom bring different areas of knowledge and expertise to the discussion.

 Geriatric medicine brings a unique area of expertise that

reaches beyond the standard decision-making parameters… creates the opportunity to consider a broader spectrum of treatment options for each patient… potential to assist with resource utilization and improve

• verall patient care.

 Consultative  collaborative transition  Geriatric medicine was invited to attend  Future directions: program refinement /

screening / education / peri-procedure delirium management pathway

 Inviting each specialty to present to the other is

enabling (2-way learning)

 Listen long enough to fully understand  Mastering ‘money-speak’

allenhuang@toh.ca